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  Ryan White Planning and Prevention Council application

 
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  • Ryan White HIV Planning Council information
  • Thank you for taking time to consider membership and complete an application for the Kansas City Transitional Grant Area (TGA) Comprehensive HIV Prevention and Care Planning Council. Please provide us with as much information as you can. The more information you provide, the more likely we will be able to utilize you to the best of your capabilities.

    Please indicate if you are applying for
    Planning Council membership
    Associate membership

    Your name:

    What county do you live in?


    Street address:

    City:

    State:

    ZIP code:

    Your e-mail:

    Fax number:

    Home phone:

    Cell phone:

    Daytime phone:

    What is the best way to contact you?


    How did you hear about the Planning Council?
    Advertisement
    Web site
    Personally recruited
    Event booth
    Referral
    Radio
    Word of mouth
    Other

    If other, please explain:


    Have you ever attended a general or committee meeting of the Planning Council?
    Yes
    No

    Gender:

    Age: Under 18
    18 to 24
    25 to 49
    50 or above

    Ethnicity or race:

    If other, please explain:


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


    Do you live with an HIV positive child?


    Do you live with an HIV positive adult?




    Optional questions for people self-identifying as having HIV or AIDS or being at-risk:

    Why are you interested in serving on the Prevention and Care Planning Council?


    Describe any experience you have had working with the community--PTA, volunteer organizations and employment:


    What skills or life experience would you bring to the Prevention and Care Planning Council?


    What committee or committees are you interested in?

    All
    Assessment and Comprehensive Planning Committee
    Finance Committee
    Prevention Committee
    Community Advocacy Committee


    Are you interested in participating in the State's Community Planning Group?