PPCoC Membership Application

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* 1. Please provide your contact information:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. What organization are you representing? (List N/A if you are applying as an individual)

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* 3. Will you be the primary CoC liaison for your organization?

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* 4. Member Category (Please check all that apply):

Non-profit Homeless Service Provider

Victim Service Provider

Faith-Based Organization

Government Entity

Business

Public Housing Agency

Social Service Provider

Mental Health Agency

Hospital/Healthcare Provider

School District

Law Enforcement

Veteran Service Provider

Affordable Housing Developer

Employment/Vocational Program

Person who has experience of homelessness (current or former)

Substance Use Treatment Provider

Other Interested Party (please specify):

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* 5. Would you be interested in participating in any of the following committees? (check all that apply)

PPCoC Ranking and Prioritization Committee

PPCoC Monitoring Committee

PPCoC Strategic Planning Committee

Coalition of Homeless Advocates and Providers (CHAP)

Youth Advisory Board (YAB)

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* 6. As a member of the Pikes Peak Continuum of Care, you must agree to the following PPCoC Responsiblities and the Conflict of Interest Policy as specified in the PPCoC Governance Charter:

PPCoC Member Responsibilities:

Members will vote directly to approve the governance framework set forth in the Governance Charter and any subsequent changes or additions to the Governance Charter

Members will review, update, and approve changes to the Governance Charter at least annually

Unless the Board selection process is changed by a subsequent amendment to the Governance Charter, members will vote annually to elect Directors to available PPCoC Board positions.

Members must comply with the conflict of interest and recusal process found in the § 578.95 Conflicts of interest of the Homeless Emergency Assistance and Rapid Transition to Housing Act of 2009 (HEARTH Act). For more information, review the entire PPCoC Governance Charter at the following link:

PPCoC Governance Charter