Membership Form

Experience & Background
1. What makes you a good candidate for membership on the Planning Council & Why are you seeing appointment to the Planning Council?
2. How would your participation on the Planning Council benefit people living with HIV/AIDS?
3. Describe trainings that you have taken related to HIV community planning, the Ryan White program, or related areas that have helped you prepare for a role as a Planning Council member.

Affiliation
Identify any agency where you serve as employee, consultant, or board member. Do not include service on consumer advisory boards or as an unpaid volunteer. Agency affiliation does not disqualify you for appointment, but may require that you not participate in certain voting procedures.
Agency 1
Agency 2
Capacity 2
(employee, consultant, board member)
Agency 3
Capacity 3
(employee, consultant, board member)

Affirmation of Member Commitment
Please read each statement and check the accompanying box.
If appointed by the Mayor, I will commit to the following:*
- Serve on the Council and serve on a committee (A minimum 4 hours per month);
- Participate in all Planning Council meetings (4th Thursday of the Month);
- Prepare for each meeting by reading any pre-distributed materials;
- Consider the needs of the community as a whole and not allow my concern to be limited to personal or special interests;
- Disclose any potential conflicts of interest to the Council or its committees;
- Participate in Planning Council orientation and trainings
Confirmation*
- I have considered my personal and professional obligations and do not believe them to be a barrier to my active participation as a committee member.
- I certify that all statements made in this application are true.

Contact Information