MEMBERSHIP APPLICATION MICHIGAN HIV/AIDS COUNCIL (MHAC) – Applications are accepted annually in the late fall. MHAC will appoint new members to three year terms. Membership on MHAC is a volunteer position. Members are expected to commit an average of 20 hours per quarter to fulfill their obligation to MHAC. Applicants are to complete the entire application, including the personal statement questions on page three. Demographic information will be used to ensure the body is diverse across expertise and identities, and reflective of the epidemic. Confidentiality: The information provided on this application will be held in confidence by the membership committee of MHAC. MHAC strives to maintain a diverse membership that represents those infected and affected by HIV in Michigan. While applicants may choose not to provide certain information, applications will be scored based on the information provided. PERSONAL INFORMATION Full Name: Mailing Address: City: State: ZIP Code: Primary Phone: Secondary phone: Email: Cell Cell Employer: City: State: EMERGENCY CONTACT INFORMATION Name of person to contact in case of emergency: Relationship to applicant: Primary phone: Secondary phone: Email: DEMOGRAPHIC INFORMATION Age Gender: How did you hear about MHAC: < age 13 30-39 Male Co-worker 14-19 years 40-49 years Female Friend 20-24 years 50-59 years Transgender (male to female) Media (Newspaper, radio) 25-29 years > 60 years Transgender (female to male) Internet prefer not to disclose Prefer not to disclose Agency (please specify): Other (please specify): Race (check all that apply): Ethnicity (check all that apply): Educational attainment: American Indian or Alaskan Native Hispanic or Latino Less than high school Asian Middle Eastern/ of Arab descent Some high school Black or African American Neither of the above High school Native Hawaiian/Pacific Islander Prefer not to disclose Some college White post-secondary Other (please specify): Undergraduate degree Prefer not to disclose Graduate degree □
MEMBERSHIP APPLICATION MICHIGAN HIV/AIDS COUNCIL – (MHAC) Applications are accepted annually in the late fall. MHAC will appoint new members to three year terms. Membership on MHAC is a volunteer position. Members are expected to commit an average of 20 hours per quarter to fulfill their obligation to MHAC. Applicants are to complete the entire application, including the personal statement questions on page three. Demographic information will be used to ensure the body is diverse across expertise and identities, and reflective of the epidemic. Confidentiality: The information provided on this application will be held in confidence by the membership committee of MHAC. MHAC strives to maintain a diverse membership that represents those infected and affected by HIV in Michigan. While applicants may choose not to provide certain information, applications will be scored based on the information provided. PERSONAL INFORMATION Full Name: Mailing Address: City: State: ZIP Code: Primary Phone: Cell Secondary phone: Cell Email: Employer: City: State: EMERGENCY CONTACT INFORMATION Name of person to contact in case of emergency: Relationship to applicant: Primary phone: Secondary phone: Email: DEMOGRAPHIC INFORMATION Age < age 13 30-39 14-19 years 40-49 years 20-24 years 50-59 years 25-29 years > 60 years prefer not to disclose Gender: Male Female Transgender (male to female) Transgender (female to male) Prefer not to disclose (please specify): How did you hear about MHAC: Co-worker Friend Media (Newspaper, radio) Internet Agency Other (please specify): Race (check all that apply): American Indian or Alaskan Native Asian Black or African American Native Hawaiian/Pacific Islander White Other (please specify): □ Prefer not to disclose Ethnicity (check all that apply): Hispanic or Latino Middle Eastern/ of Arab descent Neither of the above Prefer not to disclose Educational attainment: Less than high school Some high school High school Some college post-secondary Undergraduate degree Graduate degree
MHAC-MEMBERSHIP-APPLICATION-10-2-14-fillable.docx