Palm Beach County HIV Care Council

1. Contact Information

To help us process your membership application, please provide all of the information requested and type or print clearly.

Name:

Home Address:

City/State:

Zip Code:

Home Phone:

Cellular/Mobile Phone:

Personal E-mail: This question requires a valid email address.

Employer (If applicable):

Employer Address: This question requires a valid email address.

Employer City/State:

Employer Zip Code:

Title/Position:

Work Phone:

Work Fax:

Work Email: 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	Home	Work
I prefer to receive calls and messages at	I prefer to receive calls and messages at: Home	I prefer to receive calls and messages at: Work
I prefer to receive mail at	I prefer to receive mail at: Home	I prefer to receive mail at: Work
I prefer to receive e-mail messages at	I prefer to receive e-mail messages at: Home	I prefer to receive e-mail messages at: Work

How did you hear about the PBC HIV CARE Council?

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.

Race/Ethnicity

3. CARE Council Membership

Why do you want to be a CARE Council member?

The CARE Council meets once a month (currently on the Last Monday of each month) for a two-hour meeting (from 2pm to 4pm) in Palm Beach County. The CARE Council’s committees will require an additional two-hour commitment. Can you commit to spending four (4) hours a month on CARE Council activities?

I am a former CARE Council member re-applying:

If yes, what years did you serve?

What committee(s) are you interested in joining?

4. Special Skills and Program Involvement

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:

Clear

Signature of

6. Application Checklist

Please verify that you have completed each part of this application. Check all boxes.

Part 1: Contact Information
Part 2: Applicant Demographics
Part 3: Planning Council Membership
Part 4: Special Skills and Program Involvement
Part 5: Statement of Member Commitment
Code of Ethics Form

Palm Beach County HIV Care Council

Membership Application