COMMITTEE INTRODUCTION AND MEMBERSHIP APPLICATION INSTRUCTIONS FOR THE
NEWARK EMA HIV HEALTH SERVICES PLANNING COUNCIL


Thank you for your interest in the Ryan White Part A Planning Council. Please take a few minutes to read the information below as it is important to understand the work and responsibilities of all Planning Council committees and its committee members.

 
WHAT IS THE PLANNING COUNCIL?

The Newark Eligible Metropolitan Area (EMA) HIV Health Services Planning Council is responsible for prioritizing HIV/AIDS services based on community needs and allocating Ryan White Part A funding for these services. The Planning Council has seats for up to 34 members who represent a variety of community agencies, stakeholders, state agencies, consumers, and individuals affected by HIV/AIDS in the counties of Essex, Union, Morris, Sussex and Warren. For more information, visit www.nemaplanningcouncil.org.

The NEMA Planning Council is supported by the United Way of Greater Union County known as the Office of Planning Council Support, and works in close collaboration with the Ryan White Unit of the Newark Department of Health & Community Wellness.

 
COMMITTEE MEMBERSHIP

All members are expected to have the support of their employer (if employed) and to commit to the following:

  • Participation in monthly Planning Council committee meetings
  • Preparation for each meeting by reading any materials e-mailed to you prior to the meeting.
  • Consideration of the needs of the community over individual or agency needs


APPLICATION SUBMISSION
For further information on the application or the membership selection process please contact the Council Support Staff at Tania Guaman at Tania.Guaman@uwguc.org or Unnati Guru at Unnati.Guru@uwguc.org.
SECTION 1: CONTACT INFORMATION

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* Full Name (Please provide name as you would like it to appear in communications):

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* Full Home Address (Please include street name city, county, and zip code):

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* County

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* Home Phone Number:

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* Cell Phone Number:

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* Personal Email Address (if available):

SECTION 2: EMPLOYMENT INFORMATION 

(If applicable.)

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* Current Place of Employment and/or Community Role:

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* Full Work Address (Please include street name city, county, and zip code):

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* Work Phone Number (leave blank if not applicable):

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* Fax Number (Leave blank if not applicable):

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* Work Email Address (Leave blank if not applicable):

SECTION 3: GENERAL INFORMATION 

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* Email communication is used frequently between the Office of Planning Council Support, the Newark EMA HIV Health Services Planning Council, and its membership.
Do you have access to a computer or tablet?

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* If you do not have a computer or tablet, are you willing to work with our Support Staff to determine the best way for you to get information normally sent out by email? (This could mean you receive information via mail, text, or meeting Staff in-person to pick up information). 

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* Have you ever served on the NEMA Planning Council?

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* Have you ever served on any of the NEMA Planning Council subcommittees?

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* Do you currently serve as a member of any other HIV or health-services-related planning body, advisory board, commission, or workgroup?

SECTION 4: PERSONAL INFORMATION 

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* Date of Birth (mm/dd/yyyy) (Optional but highly encouraged):

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* Gender

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* Race/Ethnicity: (Choose all that apply to you):

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* Please select all that apply to you:

SECTION 5: EXPERIENCE, SKILLS, AND BACKGROUND

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* Please describe any areas of relevant expertise gained from personal or professional experience that you would bring to the Planning Council.

SECTION 6: COMMITTEE SELECTION

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* The Planning Council has four standing committees that support work of the Planning Council. The Executive Committee guides the work of the Council. Which of the following standing committee(s) are you interested in and will actively participate in?
NOTE: There may be some restrictions on committee representation requirements as noted on their Operating Policies and Procedures. Therefore, you might not always be able to serve on the committee of your choice.

Please check all that apply.

NOTE: There may be some restrictions on committee representation requirements as noted on their Operating Policies and Procedures. Therefore, you might not always be able to serve on the committee of your choice.
SECTION 7: STATEMENT OF COMMITMENT, SIGNATURE, & DATE

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* If appointed as a committee member, I can commit to the following minimum standards:

☐ To the best of my ability, I will attend regularly scheduled committee meetings.

☐ When I make recommendations and/ or decisions, I agree to consider the HIV/AIDS community as a whole, rather than just special interests or my personal perspectives.

☐ I agree to disclose any conflicts of interest I may have relative to issues that come before the Council and/ or Committees.

☐ I agree to keep information obtained due to participation in any activity related to the Planning Council confidential, unless otherwise given permission.

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* I acknowledge all the information provided in this application is true and correct to the best of my knowledge. I have considered my other personal and professional obligations and do not foresee them as a barrier to my full participation.

Please add your name below (in lieu of a signature):

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* Today's Date

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Time
***Please amend your membership application by contacting the Support Team whenever your contact, employment, or residence information changes.***

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