Planning Council Volunteer Application Form

Planning Council Volunteer Application Form

Contact Information

Contact Information

First Name

Middle Name

Last Name

Mailing Street

Mailing City

Mailing State

Mailing Zip Code

County

Street Address (If different than above)

City

State

Zip Code

Phone - home

Please use this format 5031234567

Phone - work

Please use this format 5031234567

Phone - cell

Please use this format 5031234567

Email

Fax (only if confidential)

Please use this format 5031234567

Preferred method of contact

Emergency Contact Name

Emergency Contact Phone

Please use this format 5031234567

Primary Language

If your primary language is not English, would you like a translator?

YesNo

The federally authorized Ryan White program requires that the Planning Council be reflective of the local HIV/AIDS epidemic. For this purpose, please identify any or all of the following categories that apply to you.

Date of Birth

Please enter DOB in this format mm/dd/yyyy

Gender

Your pronouns

Ethnicity/Race

If "other" or "multiracial", please describe

Experience

Where did you learn about the HIV Services Planning Council?

Use the Control key to select more than one answer

Have you ever worked or volunteered at an agency or organization which provides services to people with HIV/AIDS?

YesNo

If yes, please list the agencies or organizations where you worked or volunteered, and describe your position:

Describe your duties for each place you worked or volunteered.

Does your current employer or organization receive any Ryan White funding?

YesNo

If yes, please explain:

Why are you interested in serving on the HIV Services Planning Council?

Optional

The following questions are optional but helpful for statistical purposes.

If you are a person living with HIV/AIDS, are you willing to identify yourself as such?

If you are a person living with hepatitis B or C, are you willing to identify yourself as such?

Conflict of Interest Disclosure

Conflict of Interest

The Ryan White Program requires that specific categories of people in the community be represented on planning councils. Thus, some council members may also serve as employees or board members of organizations eligible for Ryan White Program funds. Other members may have other organizational affiliations or relationships with individuals who have such affiliations. Because of the potential for conflict of interest, this disclosure must be documented by all council members and applicants.

What is conflict of interest?

A conflict of interest is defined as:

Actual or perceived interest by the member in an action that results or has the appearance of resulting in personal, organizational or professional gain.

This actual or appearance of bias in the Council’s decision-making process is based on the dual role played by some council members who are affiliated in some capacity (e.g., employee, board or advisory committee member) of an organization or agency which has received, may seek or is eligible for Part A Program funds.

In most instances, conflict of interest does not refer to persons living with HIV (PLWH) whose only relationship to a Part A-funded organization or agency is as a client who receives or is eligible for services.

I have read, understand and support this definition of conflict of interest.

YesNo

Check one

Yes, I am either employed by, a consultant for, an officer of, or a board or advisory member of an organization which has received, may seek or is eligible for funding under Part A of the Ryan White program. This declaration also extends to any family member.I have no apparent conflict of interest.

If you answered "yes," for each organization you are affiliated with please list the name of the organization, your title and period of affiliation:

Volunteer Application

Privacy Information

I understand that the information I have provided on this form is confidential. By submitting this application, I understand this information will be available to the Nominations Committee for review.

I agree

YesNo

Contact Information