Membership Application

For Mayoral Appointment to the:

HIV Planning Council

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* 1. Name

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* 2. Contact Information

Street

City

Zipcode

Phone

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* 3. County of residence (please check one)

Travis

Bastrop

Caldwell

Hays

Williamson

Other (please specify your county of Residence)

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* 4. Employer (if applicable). This Information is used for Conflict of Interest purposes.

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* 5. Occupation/Job Title

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* 6. How did you hear about the HIV Planning Council?

Boards and Commission's Website

Facebook

Friend

Colleague

HIV Planning Council Member

AustinTexas.gov

Other (please specify)

None of the above

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* 7. MEMBERSHIP REQUIREMENTS: Planning Council members are required to attend the monthly Business Meeting, as well as additional scheduled Planning Council meetings, including but not limited to monthly Sub-Committee meetings. Planning Council members may expect to commit a minimum of five hours per month to HIV Planning Council-related activities and meetings. A member who misses one third of all assigned regularly scheduled committee meetings in any rolling twelve month period, including the current month shall be ineligible to continue as a member.

Check this box to indicate your understanding of and intention to adhere to the membership requirement described above.

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* 8. Please check any of the following categories that represent

your current professional and/or personal affiliation(s)

Affected Communities: People Living With HIV/AIDS --PLWHA, Caregiver of PLWHA, and/or historically underserved people)

Health care provider (including Federally Qualified Health Centers)

Local public health agency

Representative of recently incarcerated persons or an individual who was recently incarcerated and is living with HIV/AIDS

HIV/AIDS Prevention Provider

State government (Department of State Health Services, State Medicaid)

Hospital or healthcare planning agency

Organizations serving women, children, youth, and families with HIV

Grantee of other Federal HIV programs, including but not limited to providers of HIV prevention services

Mental health (including substance abuse)

HIV/AIDS community based organizations

Grantee under part C of the Ryan White Grant

Social service and homeless housing providers

None of the above

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* 9. Describe your interest in becoming a member of the HIV Planning Council.

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* 10. The mission of the HIV Planning Council is to develop and coordinate an effective and comprehensive community-wide response to HIV.

Based on your knowledge of the HIV Planning Council, what skills and experience do you have that will help support the Planning Council’s mission?

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* 11. Do you have any current or previous volunteer/community service experience?

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* 12. Please list any training and/or education related to HIV/AIDS or public health that you have received.

Federal regulations require that at least 33% of the Planning Council membership be comprised of people who use Ryan White Part A services. Either during or before your interview with the HIV Planning Council you will be asked if you are a consumer. Please contact 512-972-5806 if you need clarification. This information is confidential.

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* 13. Please list any accommodations you need to access or participate in meetings. (Example: internet accessibility, wheelchair accessibility, hearing impairment, language other than English, etc.)

Internet access to attend meetings virtually

Wheelchair access for in-person meetings

Technology access to attend meetings virtually

Translation Services

Transcription Services (for those who are hearing impaired)

Childcare Assistance to attend meetings in-person

Transportation Assistance to attend meetings in-person

Other (please specify)

Not Applicable

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* 14. Please upload a letter of recommendation. If you are representing an organization, submit a letter from someone within this organization.

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Membership Application

For Mayoral Appointment to the:

Question Title

* 1. Name

Question Title

* 2. Contact Information

Question Title

* 3. County of residence (please check one)

Question Title

* 4. Employer (if applicable). This Information is used for Conflict of Interest purposes.

Question Title

* 5. Occupation/Job Title

Question Title

* 6. How did you hear about the HIV Planning Council?

Question Title

Question Title

* 8. Please check any of the following categories that represent your current professional and/or personal affiliation(s)

Question Title

* 9. Describe your interest in becoming a member of the HIV Planning Council.

Question Title

* 10. The mission of the HIV Planning Council is to develop and coordinate an effective and comprehensive community-wide response to HIV.Based on your knowledge of the HIV Planning Council, what skills and experience do you have that will help support the Planning Council’s mission?

Question Title

* 11. Do you have any current or previous volunteer/community service experience?

Question Title

* 12. Please list any training and/or education related to HIV/AIDS or public health that you have received.

Question Title

* 13. Please list any accommodations you need to access or participate in meetings. (Example: internet accessibility, wheelchair accessibility, hearing impairment, language other than English, etc.)

Question Title

* 14. Please upload a letter of recommendation. If you are representing an organization, submit a letter from someone within this organization.

* 8. Please check any of the following categories that represent

your current professional and/or personal affiliation(s)

* 10. The mission of the HIV Planning Council is to develop and coordinate an effective and comprehensive community-wide response to HIV.

Based on your knowledge of the HIV Planning Council, what skills and experience do you have that will help support the Planning Council’s mission?