West Central Florida Ryan White Care Council Supplemental Application

Contact Information

 
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Demographics

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, Recipient and Lead Agency. *Please note this is requirement for Health Service and Resource Administration (HRSA) Reporting, all information reported is confidential.


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If you self-identify as a person living with HIV/AIDS, please indicate method of transmission:


Have you ever been convicted of any felony or misdemeanor offense?
(If Yes, please explain. You may omit minor traffic violations and any offense committed as a minor.)

Category of Representation

Ryan White HIV/AIDS Program mandated membership category or categories that I am qualified to represent: (Check as many as appropriate)

Care Council Committees

Members are required to serve on at least one committee. Please indicate which committee(s) you are interested in joining. Additional information about each committee can be found at: thecarecouncil.org.

Personal Motivation for Membership

Areas of Expertise

Personal Motivation for Membership

Active member participation is vital to the Care Council. You are committing to attend an orientation, monthly Care Council meetings, yearly retreats and to being an active member of at least one committee. Check below if you are willing to commit the 6-8 hours per month required to fully participate in the planning process?

Potential Conflict of interest

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? .