2023 Community Advisory Council Application

First Name:

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Last Name:

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Address:

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Phone:

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Age:

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My Race Is

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Please describe your race if you chose "Other"

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My gender identity is:

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Please describe your gender if you chose "Other"

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My pronouns are:

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Please describe your pronouns if you chose "Other"

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My sexual orientation is:

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Please describe your sexual orientation if you chose "Other"

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Do you currently receive services at Allies for Health and Wellbeing?

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If so, for how long?

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If so, what services have you received? (Examples: HIV medical care, STI Testing, primary care, case management, food pantry)

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Why are you interested in working with the CAC?

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Do you have any barriers to attending virtual meetings such as Zoom or Microsoft Teams?

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If yes, please describe:

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Will you be able to attend the 6 required meetings per year?

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What strengths or skills would you bring to the CAC?

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Have you had previous experience providing feedback on healthcare services or serving on advisory councils?

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If yes, please describe:

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Which issues are you passionate about discussing that have an impact on the quality of health care you receive at Allies for Health + Wellbeing?

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We make every effort to accommodate all abilities in our CAC. Are there any services we can provide (such as ASL/language interpreters) that would make the meetings more accessible for you?

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If yes, please describe:

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Is there anything else you would like us to know?

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I understand that the business of the Community Advisory Council will be conducted in a professional and respectful manner regarding the confidentiality of recipients of services. I understand that my personal information will be held in confidence. I understand that in signing below, I am giving my permission for Allies for Health + Wellbeing to review my application.

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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