Introduction and Membership Application Instructions

Thank you for your involvement in the Ryan White Part A Planning Council. Please take a few minutes to read the information below as it is important to understand the work and responsibilities of all Planning Council and committee members.

WHAT IS THE PLANNING COUNCIL?
The Newark Eligible Metropolitan Area (EMA) HIV Health Services Planning Council is responsible for prioritizing HIV/AIDS services based on community needs, allocating Ryan White Part A funding for these services, conducting an annual Needs Assessment, establishing a standard of care based on best practices, developing and following a comprehensive plan, evaluating service effectiveness, assessing the administrative functions of the grant, and other activities which maintain and improve the EMA system of care.

The Planning Council has seats for up to 34 members who represent a variety of community agencies, stakeholders, state agencies, consumers, and individuals affected by HIV/AIDS in the counties of Essex, Union, Morris, Sussex and Warren. Visit www.nemaplanningcouncil.org for additional information about the Planning Council and its subcommittees.

The NEMA Planning Council is supported by the United Way of Greater Union County known as the Office of Planning Council Support, and works in close collaboration with the Ryan White Unit (Recipient) of the Newark Department of Health & Community Wellness.


PLANNING COUNCIL MEMBERSHIP
The term for elected NEMA Planning Council members is two years with the possibility of reappointment. All members are expected to have the support from their employer (if employed) and to commit to the following:

-Participation in monthly Planning Council meetings (held the third Wednesday of the month) as well as monthly participation in at least one sub-committee meeting

-Preparation for each meeting by reading any materials sent

-Consideration of the needs of the community over individual or agency needs


APPLICATION SUBMISSION
For further information on the application or the membership selection process please contact the Council Support Staff at Roberto Benoit at roberto.benoit@unitedwayguc.org or Richell Garcia at richell.garcia@unitedwayguc.org
SECTION 1: CONTACT INFORMATION

(The Mayor's Office of the City of Newark requires all information on Section 1 for membership appointment.)

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* 1. Full Name (Please provide name as you would like it to appear in communications):

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* 2. Full Home Address (Please include street name city, county, and zip code):

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* 3. Home Phone Number:

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* 4. Cell Phone Number:

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* 5. Personal Email Address:

SECTION 2: EMPLOYMENT INFORMATION

(If applicable.)

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* 6. Current Place of Employment and/or Community Role:

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* 7. Full Work Address (Please include street name city, county, and zip code):

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* 8. Work Phone Number (leave blank if not applicable):

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* 9. Fax Number (leave blank if not applicable):

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* 10. Work Email Address (leave blank if not applicable):

SECTION 3: RESUME

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* 11. RESUME – Please be sure to include your resume or CV with your application, if you have one available. Newark requires a resume for working people. Community members are not required to submit this item.

PDF, DOC, DOCX, JPG, JPEG file types only.
Choose File
SECTION 4: GENERAL INFORMATION

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* 12. Email communication is used frequently among the Office of Planning Council Support – United Way of Greater Union County - the Newark EMA HIV Health Services Planning Council, and its membership. Do you have access to a computer or tablet?

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* 13. If you do not have a computer or tablet, are you willing to work with our Support Staff to determine the best way for you to get information normally sent out by email? (This could mean you receive information via mail, text, or meeting Staff in-person to pick up information).

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* 14. Have you ever served on the NEMA Planning Council?

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* 15. Have you ever served on any of the NEMA Planning Council subcommittees?

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* 16. If we are unable to seat you at this time, would you like to be considered for subsequent seats as vacancies become available?

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* 17. If we are unable to seat you at this time, would you like to Continue receiving updates about Planning Council activities?

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* 18. Do you currently serve as a member of any other HIV or health-services-related planning body, advisory board, commission, or workgroup?

SECTION 5: PERSONAL INFORMATION
The  Planning Council is required to (1) ensure that its membership is reflective of demographics (race, age, and gender/ethnicity) of the people living with HIV/AIDS in the EMA; (2) include representation from a range of federally mandated categories; and (3) include at least 33% of unaffiliated people living with HIV/AIDS (this refers to consumers who do not have a conflict of interest, meaning they are not staff, paid consultants or Board members of Part A-funded agency) who receive Part A services in the Newark EMA. To help monitor and meet these legislative requirements, the following personal information is requested from you.

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* 19. Date of Birth:

  Month Day Year
Please enter:

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* 20. Gender

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* 21. Race/Ethnicity (Choose all that apply):

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* 22. HIV Serostatus

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* 23. Please select all that apply to you from the following groups.

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* 24. Please select all that apply to you:

SECTION 6: EXPERIENCE, SKILLS, AND BACKGROUND

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* 25. Please describe any areas of relevant expertise gained from personal/ lived OR professional experience that you would bring to the Planning Council.

SECTION 7: COMMITTEE SELECTION

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* 26. The Planning Council has four standing committees that support work of the Planning Council. The Executive Committee guides the work of the Council. Which of the following standing committee(s) are you interested in and will actively participate in?
NOTE: There may be some restrictions on committee representation requirements as noted on their Operating Policies and Procedures. Therefore, you might not always be able to serve on the committee of your choice.

Please check all that apply.

NOTE: There may be some restrictions on committee representation requirements as noted on their Operating Policies and Procedures. Therefore, you might not always be able to serve on the committee of your choice.
SECTION 8: STATEMENT OF COMMITMENT, SIGNATURE & DATE

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* 27. If appointed as a member of the Planning Council, I am able to commit to the following minimum standards:

☐ A full membership term of two (2) years

☐ To the best of my ability, I will attend regularly scheduled committee meetings for my assigned committee

☐ When I make recommendations and/ or decisions, I agree to consider the HIV/AIDS community as a whole, rather than just special interests or my personal perspectives

☐ I agree to disclose any conflicts of interest I may have relative to issues that come before the Council and/ or Committees

☐ I agree to keep sensitive information obtained about other Council members, including HIV status, confidential, unless otherwise given permission.

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* 28. I acknowledge all the information provided in this application is true and correct to the best of my knowledge. I have considered my other personal and professional obligations and do not foresee them as a barrier to my full participation on the Planning Council.

Please add your name below (in lieu of a signature):

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* 29. Today's Date:

Date
Time
***Please amend your membership application by contacting the Support Staff whenever your contact, employment, or residence information changes.***

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