ADAP Advocacy Association's AIDS Drug Assistance Program Advisory Council

Council Application

PLEASE READ BEFORE COMPLETING YOUR APPLICATION:

Please complete the following application to participate on the ADAP Advocacy Association's AIDS Drug Assistance Program (ADAP) Advisory Council. Your answers will remain strictly confidential and the application will not be shared with anyone, or any organization. Completion of the application does not guarantee an invitation to serve on the council.

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* 1. Please enter your complete contact information:

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Country:

Email Address: *

Phone Number: *

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* 2. Are you HIV-positive?

Yes

Don't Know

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* 3. Are you currently receiving services under the AIDS Drug Assistance Program (ADAP)?

Yes

Don't Know

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* 4. At any time in the past did you receive services under the AIDS Drug Assistance Program (ADAP)?

Yes

Don't Know

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* 5. Please check all that apply:

I currently serve on my State ADAP Drug Formulary Advisory Committee

I currently serve on my local HIV Planning Council

I currently am employed by an agency under the State Department of Health

I currently am employed by an AIDS Service Organization or Community-Based Organization

I currently volunteer for an AIDS Service Organization or Community-Based Organization

None of the above

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* 6. I understand that my application does not guarantee that I will be invited to serve on the ADAP Advisory Council.

Yes; I understand and I agree.

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* 7. I understand that if my application to serve on the ADAP Advisory Council is approved, then my participation will be strictly voluntary and I will not be compensated for my time.

Yes; I understand and I agree.

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* 1. Please enter your complete contact information:

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* 2. Are you HIV-positive?

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* 3. Are you currently receiving services under the AIDS Drug Assistance Program (ADAP)?

Question Title

* 4. At any time in the past did you receive services under the AIDS Drug Assistance Program (ADAP)?

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* 5. Please check all that apply:

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* 6. I understand that my application does not guarantee that I will be invited to serve on the ADAP Advisory Council.

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* 7. I understand that if my application to serve on the ADAP Advisory Council is approved, then my participation will be strictly voluntary and I will not be compensated for my time.

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* 8. Why do you wish to serve on our ADAP Advisory Council? (25 word minimum)