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* 1. Applicant Name

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* 2. Email Address

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* 3. Mailing Address

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* 4. County of residence

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* 5. Are you currently an Oregon Health Plan (OHP) member?

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* 6. Are you a guardian to a child or person on OHP?

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* 7. Racial/Ethnic Background (check all that apply)

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* 8. Languages spoken at home

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* 9. What is your gender?

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* 10. Which category below includes your age?

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* 11. Prioritized identities and lived experiences

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* 12. Why are you interested in joining Health Share’s Council? How do you plan to bring member/consumer perspective to the Council? What do you hope to gain out of serving in this Council?

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* 13. Please share a successful experience you’ve had working on an advisory committee or council. What made that specific experience valuable for/to you? Note the contributions you brought to the group, and how you have grown as a result of it.

If no previous experience, please share how you plan to contribute and what support you need (ex. training, time).

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* 14. Please describe your existing connection/relationships with local historically marginalized communities.

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