Application for Membership for 2012- 2013 Term

2012-13 HPC Call for Application (Adobe .pdf format)

SC HPC Membership Application 2012-13 Term (MSWord .doc format)

SC HPC Q & A for 2012 (MSWord .doc format)

If you are interested in serving on the HPC, please complete the attached application and return it to Attention: Donald Wood, via mail at Capitol Consultants, PO Box 1763, Columbia, SC 29202, fax at 803-252-0589, or hand-deliver to 1122 Lady Street, Suite 1115, Columbia, SC 29201. Please print legibly or type. All applications must be completed and received no later than Friday, October 7, 2011.

All information provided in this application will be kept CONFIDENTIAL.

South Carolina HIV Planning Council

MEMBERSHIP APPLICATION

Name: ____________________________________

Date of Birth (month/day/year): _________________________________________________

Home Contact Information

Home Mailing Address: ________________________________________________________

City, State, Zip Code: _________________________________________________________

County of Residence: _________________________________________________________

Home Telephone Number: (________) __________________________________________

Alternate Phone (cell/other): (________) __________________________________________

Home Fax Number: (________) _________________________________________________

Home E-mail Address: _________________________________________________________

WORK CONTACT Information

q Not applicable

Agency/Organization:

Mailing Address:

City, State, Zip Code

Counties served: _______________________________________________________________________

_____________________________________________________________________________________

Work Telephone Number: ( ) ________________________________________________

Work Fax Number: ( )

Work E-mail Address: __________________________________________________________________

Person to Contact in Case of Emergency:

Name: _______________________________________________________________________________

Phone Numbers:

Education:

Name and Location of School	Highest Education Level Achieved (Diploma, Certificate, Degree)	Major/Minor
Example: Eau Claire HS Columbia, SC	Diploma	Not Applicable (NA)

1.         Gender (Select one):

q       Female

q       Male

q       Transgender/Intersexed

2.         Ethnicity (Select one):

q       Hispanic/Latino

q       Non-Hispanic/Latino

3.         RACE (Select one):

q       More Than One Race

q       Black or African American

q       American Indian/Alaska Native

q       Asian

q       Native Hawaiian or Pacific Islander

q       White or Caucasian

q       Other (Please specify):__________________________________

4.         REPRESENTATION OF SEXUAL ORIENTATION, HIV EXPOSURE RISK and STATUS: (Confidential)

We ask you to divulge your categories of Sexual Orientation, HIV Exposure Risk and HIV Status as that information is shared by category (no individual identifiers) to ensure representation of all populations.

A. My Sexual Orientation

q       Heterosexual

q       Bisexual

q       Homosexual

q       Other (Please specify): _

B. My HIV Exposure Risk Category (Select one answer that best describes your risk)):

q       Man who has Sex with Men (MSM)

q       High Risk Heterosexual

q       Injecting Drug User (IDU)

q       MSM/IDU

q       Perinatal (exposure/infection as a result of having a mother with HIV infection)

q       Other (please specify): _________________________

C. My HIV Status (Select one):

q       Positive

q       Negative

q       Unknown

5. A and B. Please place a �1� in the box that best describes your primary area of expertise, and a �2� in the box that describes your secondary area of expertise:

Professional and Community Representation

Area of Expertise

Health department HIV/AIDS staff

Health department STD/STI staff

Health department hepatitis staff

Health department tuberculosis staff

Health department epidemiologist

Other health department staff (identify):

Non-Health Department Staff:

Health or health services researchers

Program evaluators

Behavioral or social scientists

Representatives of the substance abuse community

Representatives of the mental health community

Representatives of the education community

Representatives of the corrections/criminal justice community

Medical doctors

Staff from community-based HIV prevention agencies

Staff from community-based social service agencies (includes services for homeless persons)

Faith leaders

Community members interested in or affected by HIV/AIDS

Staff from Ryan White HIV Care and Support Services

Other:

VI.A. Preferred Choice of Committee
From the three standing committees of the HIV Planning Council with open membership, please rank order your choice of committees on which you wish to serve (1 being most desired, 3 being least desired):
_____ Care and Support Services
_____ Needs Assessment
_____ Prevention

VI.B. Consumer Advisory Committee

If you are a person living with HIV/AIDS or have someone in your household living with HIV/AIDS, are you interested in serving on the Consumer Advisory Committee (which meets on separate meeting days from the HIV Planning Council)? Please circle one:               Yes                  No                   N/A
VII. Skills and Experience
From the list of HIV-related services listed below, please check all that you have experience in providing.
            ____ Advocacy                                             ____ Case Management
            ____ Clinical Care                                         ____ Counseling and Testing
            ____ Health Education/Risk Reduction            ____ Housing
            ____ Mental Health Services                           ____ Outreach
            ____ Partner Notification                                ____ Substance Abuse Services
            ____ Other (please specify: _______________________________________________________
            ______________________________________________________________________________

Questions

1. Why are you seeking membership on the SC HIV Planning Council? What do you have to offer as a member of the Planning Council?
**

.

2. Briefly describe your involvement working with HIV prevention and/or care in your local community. [If you are a staff member of an organization involved in HIV/STD prevention and/or care, please include a copy of your resume or curriculum vita (CV).]

.

3. What boards, task forces, and other planning or community groups do you serve on or represent?

.*

4. Please provide the contact information for three (3) people who can affirm the information you have provided.

Name # 1______________________________________________________________________

Title: __________________________________________________________________________

Agency/Organization: ____________________________________________________________

Mailing Address: ________________________________________________________________

______________________________________________________________________________

Phone Number: _________________________________________________________________

Name # 2 ______________________________________________________________________

Title: __________________________________________________________________________

Agency/Organization: ____________________________________________________________

Mailing Address: ________________________________________________________________

______________________________________________________________________________

Phone Number: _________________________________________________________________

Name # 3_________________________________________________________________________

Title: __________________________________________________________________________

Agency/Organization: ____________________________________________________________

Mailing Address: ________________________________________________________________

______________________________________________________________________________

Phone Number: _________________________________________________________________

________ (initial) I have read the commitment requirements and responsibilities for the SC HIV Planning Council and am able to fulfill these requirements and responsibilities if I am selected. I understand that the commitment is for a specified term which requires attendance at HPC meetings and participation in Standing Committee meetings and conference calls.

________ (initial) I understand, affirm, and agree that all statements on this form are true and accurate and that any misrepresentation or omission or facts may result in my being disqualified for membership on the SC HIV Planning Council.

Signature Date

Signature of Parent/Guardian (if under 18 years of age) ________________________________________

SC HIV Planning Council

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South Carolina HIV Planning Council

MEMBERSHIP APPLICATION

Name: ____________________________________

Home Contact Information

WORK CONTACT Information

q Not applicable

1. Gender (Select one):

2. Ethnicity (Select one):

4. REPRESENTATION OF SEXUAL ORIENTATION, HIV EXPOSURE RISK and STATUS: (Confidential)

A. My Sexual Orientation

B. My HIV Exposure Risk Category (Select one answer that best describes your risk)):

C. My HIV Status (Select one):

VI.B. Consumer Advisory Committee

Questions