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Palm Beach County HIV Care Council

Membership Application

1. Contact Information

To help us process your membership application, please provide all of the information requested and type or print clearly.
This question requires a valid email address.
This question requires a valid email address.
This question requires a valid email address.
Planning Council Support staff will be contacting you via mail, e-mail, and/or telephone about meeting activities. Please tell us how you prefer to be contacted:
Space Cell HomeWork
I prefer to receive calls and messages at
I prefer to receive mail at
I prefer to receive e-mail messages at
2. Applicant Demographics

Please check the box for each category with which you most closely identify. Feel free to include any additional information that you use to describe yourself on the ‘other’ lines. Your response will be kept CONFIDENTIAL and available only to CARE Council Support staff and the members of the Nominating Committee.
I am
My age range is
I am a person living with HIV (PLWH)
I am a person living with Hepatitis B
I am a person living with Hepatitis C
If you are a person living with HIV, are you willing to self-identify as such for legal documents and CARE Council activities?*
Do you receive services at any of the agencies funded through Part A?
Compass, Found care, Legal Aid Society of Palm Beach County, Florida Dept of Health, AHF, Health Council of South East Florida

*Disclosure of HIV status is encouraged, but not required for membership.
You MUST choose one *This question is required.
Choose as many as applicable, but you MUST choose at least one *This question is required.
You may choose one or more from the following Racial/Ethnic Groups
3. CARE Council Membership
I am a former CARE Council member re-applying:
What committee(s) are you interested in joining?
4. Special Skills and Program Involvement
What special skills or areas of expertise would you bring to the CARE Council?
Please check all that apply.

I am affiliated as an employee, consultant, or board member with the following types of organizations, agencies, or programs:
5. Statement of Member Commitment

As a member of the Palm Beach County HIV CARE Council, you are subject to Florida’s Government-In-The-Sunshine requirements. Certain personal requirements are placed upon you and your conduct with other members, the public at large and the Department of Community Services. Upon notification of appointment, all new members will undergo a new member orientation which will include complete discussion of Government-In-The- Sunshine.

Certain assurances pertaining to potential conflicts-of-interest must be executed by all members of the Palm Beach County HIV CARE Council. Disclosure of business and personal relationships with agencies or individuals benefitting from award of Ryan White Funding must be given each time an issue is raised which could present a conflict of interest. Council members must indicate prior to discussion any potential conflicts, and must abstain from voting on issues presenting a potential conflict.
Signature of applicant:
Signature of
6. Application Checklist
Please verify that you have completed each part of this application. Check all boxes.