Your Way Home Continuum of Care Membership Form

Membership in the Your Way Home Continuum of Care (CoC) is free and open to any person or organization committed to ending and preventing homelessness in Montgomery County, Pennsylvania. Join today!

All CoC members must agree to uphold Your Way Home's mission to end and prevent homelessness and its Statement of Racial Equity Principles and Values, which can be read here: Statement of Racial Equity Principles and Values.

Membership is open to any individual that is committed to ending and preventing homelessness in Montgomery County. Individuals may be residents, people with lived experience of homelessness, Your Way Home program participants, and staff and volunteers who work for a nonprofit/faith/community-based organization, business, governmental entity, or school/university.

Question Title

* 1. Are you applying to be a Your Way Home CoC Individual member (open to all) or an Agency member (a single designated representative or employee of a CoC-funded service provider agency)?

Individual Member

Agency member

Question Title

* 2. Tell us about yourself.

Name *

Organization (if any)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number *

Question Title

* 3. Your Way Home collects and discloses aggregate (not your personal/individual) CoC membership diversity information. Please answer this question if you agree to the inclusion of this information.

Have you ever personally experienced literal homelessness?

Yes

Question Title

* 4. Which of the following groups do you represent in Montgomery County? (Check all that apply.)

Affordable Housing Developer

Agency Serving Survivors of Human Trafficking

CDBG/HOME/ESG Entitlement Jurisdiction

CoC-Funded Victim Service Provider

CoC-Funded Youth Service Provider

Disability Advocate

Disability Service Organization

Domestic Violence Advocate

EMS/Crisis Response Team(s)

Person with Lived Experience of Homelessness

Hospital

Indian Tribe/Tribal Organization

Law Enforcement

Lesbian, Gay, Bisexual, Transgender (LGBTQIA2S+) Advocate

LGBTQIA2S+ Service Organization

Local Government Staff/Official

Local Jail

Mental Health Service Organization

Mental Illness Advocate

Non-CoC Funded Youth Homeless Organization

Non-CoC Funded Victim Service Provider

Organization led by and serving Black, Brown, Indigenous and other People of Color (BIPOC)

Organization led by and serving LGBTQIA2S+ Persons

Organization led by and serving people with disabilities

Other homeless subpopulation advocate

Other Victim Services Organization

Public Housing Authority

School Administrator/Homeless Liaison

Street Outreach Team

Substance Abuse Advocate

Substance Abuse Service Organization

Youth Advocate

Youth Homeless Organizations

Youth Service Provider

None of the above

Other (please specify)

Question Title

* 5. On which of the following Your Way Home Advisory or Action Teams would you consider joining? (Check all that apply; Agency members must select at least one.)

Homeless Management Information Systems (HMIS) Data and Outcomes Action Team

Permanent Housing Opportunities

Regional CoC Partnerships (e.g., Bucks, Chester, Delaware, Lehigh, Philadelphia Counties)

Homeless Veterans Task Force

Lived Experience Advisory Team

Code Blue Action Team

Equitable Access Action Team

Eviction Prevention Advisory Team

Philanthropic Fund Action Team

LGBTQIA2S+ Engagement Action Team

Youth Advisory Board

Coordinated Entry Redesign Action Team

None of the above

Question Title

* 6. Do you require any special accommodations or assistance to participate in CoC meetings? If yes, please specify. If no, please skip to the next Question.

In-Person Meetings

Virtual/Online Meetings

Conference Call/Telephone Meetings

Question Title

* 7. *Membership Acknowledgement. I affirm that for my Your Way Home CoC membership to be in good standing, I must:

1. Uphold Your Way Home's mission to end and prevent homelessness and its Statement of Racial Equity Principles and Values.

2. Attend at least 50% of Your Way Home CoC membership meetings and 50% of Advisory or Action Team meetings on which I serve.

Acknowledged (check this box)

Question Title

* 8. Your Way Home collects and discloses aggregate (not your personal/individual) CoC membership diversity information. Please answer this question if you agree to the inclusion of this information.

What is your gender identity?

Woman

Transgender

Man

Genderqueer or non-binary

Prefer not to answer

Other (please specify)

Question Title

* 9. Your Way Home collects and discloses aggregate (not your personal/individual) CoC membership diversity information. Please answer this question if you agree to the inclusion of this information.

What is your race or ethnicity? (Check one or more.)

Hispanic, Latina/Latino/Latinx, or Spanish Origin

Black or African American

White

Native Hawaiian or Other Pacific Islander

American Indian or Alaskan Native

Asian or Asian American

Prefer not to answer

Other (please specify)

Your Way Home Continuum of Care Membership Form

Question Title

* 1. Are you applying to be a Your Way Home CoC Individual member (open to all) or an Agency member (a single designated representative or employee of a CoC-funded service provider agency)?

Question Title

* 2. Tell us about yourself.

Question Title

* 3. Your Way Home collects and discloses aggregate (not your personal/individual) CoC membership diversity information. Please answer this question if you agree to the inclusion of this information. Have you ever personally experienced literal homelessness?

Question Title

* 4. Which of the following groups do you represent in Montgomery County? (Check all that apply.)

Question Title

* 5. On which of the following Your Way Home Advisory or Action Teams would you consider joining? (Check all that apply; Agency members must select at least one.)

Question Title

* 6. Do you require any special accommodations or assistance to participate in CoC meetings? If yes, please specify. If no, please skip to the next Question.

Question Title

Question Title

* 8. Your Way Home collects and discloses aggregate (not your personal/individual) CoC membership diversity information. Please answer this question if you agree to the inclusion of this information. What is your gender identity?

Question Title

* 9. Your Way Home collects and discloses aggregate (not your personal/individual) CoC membership diversity information. Please answer this question if you agree to the inclusion of this information. What is your race or ethnicity? (Check one or more.)

* 3. Your Way Home collects and discloses aggregate (not your personal/individual) CoC membership diversity information. Please answer this question if you agree to the inclusion of this information.

Have you ever personally experienced literal homelessness?

* 8. Your Way Home collects and discloses aggregate (not your personal/individual) CoC membership diversity information. Please answer this question if you agree to the inclusion of this information.

What is your gender identity?

* 9. Your Way Home collects and discloses aggregate (not your personal/individual) CoC membership diversity information. Please answer this question if you agree to the inclusion of this information.

What is your race or ethnicity? (Check one or more.)