The Care Council - Membership

West Central Florida Ryan White Care Council

Serving the Tampa Bay Area & Surrounding Communities

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Care Council Membership

Online Membership Application

Please pay attention to each question and make sure you answer all parts of a question.

Please be aware that the Care Council is a public body. You will receive mail, email, and/or phone calls from the members and the staff. Also, the information you enter here will be sent to the Care Council Support Staff via standard email. If you are uncomfortable providing this information online, you may download and print the membership application which can then be faxed, mailed, or delivered in person.

Name:
Address:
City:
State:		Zip:
Home Phone:	( ) -
Cell Phone:	( ) -
Work Phone:	( ) - Ext:
Fax:	( ) -
Home Email:
Work Email:

(Name, and at least one phone number or email address, is required!)

CONFIDENTIAL
Care Council composition must reflect the demographics of the HIV/AIDS epidemic and include representation from federally mandated categories. Your responses will be kept CONFIDENTIAL and will be available only to the authorized members of the Care Council, Council support staff and Grantee.

Gender:	Male Female Transgender

Date of Birth:	/ /

Ethnicity: (select one)	Black (non-Hispanic) Asian/Pacific Islander Hispanic American Indian/Alaskan Native White (non-Hispanic) Other (Please Specify: )

Category of Representation: (check all that apply to you)	Individuals living with HIV disease or AIDS Healthcare providers, including Federally Qualified Health Centers Community Based Organization (CBO) serving affected populations/AIDS Service Organization (ASO) Social Service Provider, including housing and homeless services provider Mental Health Provider Substance Abuse Provider Local Public Health Agency Hospital or other healthcare planning agency Affected Communities, including PLWH, Individuals co-infected with Hepatitis B or C and historically underserved subpopulations (people of color, migrant workers, women, homeless) Non-elected community leader State Medicaid Agency Ryan White State Part B Agency Ryan White Part C Ryan White Part D or organizations addressing the needs of children, youth, and families with HIV Grantees of other federal HIV programs such as HIV Prevention programs, AETC (AIDS Education and Training Center ) , Dental, SPNS (Special Projects of National Significance), and HOPWA (Housing Opportunities for Persons with AIDS) Representatives of/or formerly-incarcerated PLWH

Describe your personal motivation for wanting to be a member of the Care Council:

Please list any areas of expertise that you can bring to the Care Council:	Special skills, knowledge, training, life experiences, volunteer experiences, boards or commissions, especially those focusing on HIV issues:

Active member participation is vital to the Care Council: (check box to confirm) Required!	You are committing to attend an orientation, monthly Care Council meetings, yearly retreats and to being an active member of at least one committee. I am willing to commit the 8-10 hours per month required to fully participate in the planning process.

Members are required to serve on at least one committee. Please indicate which committee(s) you are interested in joining: (check as many as desired)	Client Services Health Services Advisory Membership, Nominations, Recruitment and Training Minority Advocacy (MAC) Planning and Evaluation (P&E) Resource Prioritization and Allocation Recommendations Committee (RPARC) Rural Issues Women, Infants, Children, Youth and Families (WICY&F)
CONFLICT OF INTEREST DISCLOSURE:
Rules of law and ethics prohibit members from participating in and voting on matters in which they may have a direct/indirect financial interest. List any potential Conflicts of Interest (i.e., you or a significant other are a member of, employee of, or have a direct/indirect financial interest in an organization seeking/receiving Ryan White funds: (Agency, Relationship, Period of Affiliation)
(Make sure you have provided at least your name, a contact phone or email, and that you have checked the box to commit to participation!)

Current Affairs

Upcoming
Events
(NOTE: Subject to change!)

Date: Thu, 05/24/12
Time: 9:30 AM - 11:00 AM
WOMEN, INFANTS, CHILDREN, FAMILY, YOUTH COMM MTG
at Suncoast Hospice - St. Petersburg
View Details....

Date: Wed, 06/06/12
Time: 1:30 PM - 3:30 PM
CARE COUNCIL Meeting
at The Children's Board
View Details....

Date: Fri, 06/08/12
Time: 11:00 AM - 1:00 PM
MINORITY ADVOCACY COMM MTG
at Spring Oaks
View Details....

Date: Thu, 06/14/12
Time: 9:30 AM - 11:00 AM
PLANNING & EVALUATION COMM
at No May meeting
View Details....

Date: Thu, 06/14/12
Time: 11:00 AM - 12:30 PM
RPARC COMMITTEE
at No May mtg.
View Details....

Date: Mon, 06/18/12
Time: 9:00 AM - 10:30 AM
CLIENT SERVICES COMM MEETING
at Metro Wellness & Community Centers - Tampa
View Details....

Date: Mon, 06/18/12
Time: 11:00 AM - 12:30 PM
MEMBERSHIP COMM MEETING
at Metro Wellness & Community Centers - Tampa
View Details....

Date: Wed, 06/20/12
Time: 1:30 PM - 2:30 PM
RURAL ISSUES COMMITTEE
at Polk County Specialty Care Clinic
View Details....

Date: Thu, 06/21/12
Time: 2:00 PM - 3:30 PM
HEALTH SERVICES ADVISORY COMM
at no meeting this month
View Details....

Date: Thu, 06/28/12
Time: 9:30 AM - 11:00 AM
WOMEN, INFANTS, CHILDREN, FAMILY, YOUTH COMM MTG
at Suncoast Hospice - St. Petersburg
View Details....

View Full Calendar