Minnesota Council for HIV/AIDS Care and Prevention Application Form

                                    

Thank you for your interest in HIV care and prevention planning in Minnesota!

This community planning group is essential for the ongoing provision of prevention and care services in Minnesota. Member duties include identifying communities to target for prevention interventions, prioritizing service areas and allocating Ryan White HIV/AIDS Treatment Extension Act of 2009 funding for HIV care services. Applications for the Council are accepted throughout the year and are kept on file for one year. New members are elected as needed. The Council is a public body. The names of Council members are public information. All Council and committee meetings are open to the public. Meeting minutes are available to the public and are posted on the Council website. 
 
This volunteer position will require your attendance at the following:
1.   Participate in a New Member Orientation Session (6-8 hours);
2.   Serve a term of two (2) years.
3.   Attend monthly meetings and serve on at least one (1) standing committee;
4.   Commit to a minimum of 8-10 hours per month to Council business; including attendance at Council meetings, committee meetings and preparation time;
5.   Attend other training opportunities as appropriate.
6.   Participate fully in all responsibilities as mandated by federal legislation. 
 
Members requiring mileage reimbursement for meetings will need to provide their valid driver's license number and street mailing address.  
 
Completing this form will help the Membership and Training Committee assess the qualifications of applicants, and aid in their ability to make nominations for membership. Please recognize you will have an opportunity to expand upon your answers during a possible interview.
 
If you need assistance, including disability, completing this form contact Jeremy Stadelman, Minnesota Council for HIV/AIDS Care and Prevention, 525 Portland Ave S, MCL963, Minneapolis, MN  55415, Phone: 612-596-7894, 1-888-638-3224, Jeremy.stadelman@hennepin.us.


Contact information

 (Required fields are indicated with *)  (Required fields are indicated with *)
Format: mm/dd/yyyy
Can this email address be used for Council correspondence? Can this email address be used for Council correspondence?
Do you check your email at least two times a week? Do you check your email at least two times a week?


Please check all that apply:

Gender Gender
Ethnicity Ethnicity
Race Race
Sexual Orientation Sexual Orientation


HIV and Consumer Status

HIV Status HIV Status
HIV ExposureTo the best of your knowledge, what was most likely your HIV exposure risk? HIV Exposure

To the best of your knowledge, what was most likely your HIV exposure risk?
Current or former injection drug user (IDU) Current or former injection drug user (IDU)
Have you been incarcerated in the past 3 years? Have you been incarcerated in the past 3 years?
Are you co-infected with HIV and Hepatitis B or Hepatitis C? Are you co-infected with HIV and Hepatitis B or Hepatitis C?


Agency Affiliation

Are you currently employed by, doing consulting work for, or sit on the board of directors of an organization that provides HIV/AIDS services? (This does not include consumer boards or community advisory boards.) Are you currently employed by, doing consulting work for, or sit on the board of directors of an organization that provides HIV/AIDS services?
(This does not include consumer boards or community advisory boards.)
 Employer  Employer
Do you have employer permission to attend Council and Committee meetings as part of your job?
Do you have employer permission to attend Council and Committee meetings as part of your job?
Have you attended MN Council for HIV/AIDS Care and Prevention meetings in the past? Have you attended MN Council for HIV/AIDS Care and Prevention meetings in the past?
Service Sector Affiliations - Check all that apply, and if you are a Provider, Recipient, or Both Service Sector Affiliations - Check all that apply, and if you are a Provider, Recipient, or Both
DescriptionsNo Description
TopicsProviderRecipientBoth
Health-care provider, including Federally Qualified Health Centers
Community-based organization serving affected populations/AIDS Service Organization (ASOs)
Social services, including housing and homeless services
Mental health services
Substance-abuse services
Local public health agency
Hospital planning agency or other health-care planning agency
Affected community member (either HIV community or underserved population community)
State Medicaid Program
Ryan White Part B Program
Ryan White Part C Program
Ryan White Part D Program
Organizations addressing the needs of children, youth and families with HIV
Other Federal HIV Program, including HIV prevention programs
Formerly-incarcerated person living with HIV/AIDS or representative of this group
What special skills can you bring to the group? Mark all that apply: What special skills can you bring to the group? Mark all that apply:
In 50 words or less, please tell us why you are interested in joining the group.
Please note: This information is shared with Council members at the time your name is considered for membership.
By signing this application, you authorize the Council staff to provide this information to the Membership and Training Committee members for review.You are not legally required to provide any of the requested information. However, it generally is to your benefit to provide it. If you do not provide the information asked, the Council will be unable to determine if you meet eligibility criteria for Council membership and the Council may not be able to contact you. All data collected and stored may be shared with the Membership and Training Committee and Council staff, or only upon court order or the State Auditor as authorized by law. By signing this application, you authorize the Council staff to provide this information to the Membership and Training Committee members for review.

You are not legally required to provide any of the requested information. However, it generally is to your benefit to provide it. If you do not provide the information asked, the Council will be unable to determine if you meet eligibility criteria for Council membership and the Council may not be able to contact you. All data collected and stored may be shared with the Membership and Training Committee and Council staff, or only upon court order or the State Auditor as authorized by law.
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