Tennessee HIV|AIDS Consortia Sign Up

Name:

Company

Mailing Address:

City:

State / Province:

Zip / Postal code:

Country:

Home Phone Number:

Other Phone Number:

Email Address:

Gender:

Age:

Ethnicity

Other:

Professional Skills

Other:

What region are you representing?

Are you interested in serving on the Regional Community Planning Group (RCPG)?

Are you interested in serving on a Consortia Committee?

Are you currently serving as a Committee Chair?

Are you interested in serving as a Committee Chair?

Which Consortia Committee do you serve as Chair?

Which Consortia Committee are you interested in serving as Chair?

Select one or more of the following Consortia Committees:

Members of the MSM Task Force must identify as MSM, gay, bisexual, or same-gender-loving (SGL) men. Do you identify as either?

Conflict of InterestThe Consortium of Ryan White HIV/AIDS Program has members who are affiliated in a professional, personal, or organization manner with organizations that have or may request or receive funding authorized under Part B of the Ryan White Treatment Modernization Act. Due to the potential for conflict of interest, this Disclosure Form has been adopted by Community HIV/AIDS Partnership and must be completed by all current and future group members and presented to the Community HIV/AIDS Partnership Secretary or Lead Agent's representative. I certify that: I have read, understand, and support the conflict of interest statement. I understand that failure to disclose conflict of interest will result in punitive actions from the Executive Committee. I and/or a family member serve or have served in the past twelve months in a staff, consultant, officer, board member, or key volunteer capacity with the following organization(s) which has/have received, may seek, or is/are eligible to receive funding for AIDS care and services.

Do you have any affiliations that might be considered a Conflict of Interest?

Include name of organization, title, and period of affiliation:

General Expectations

1. Know the Consortium mission, purpose, programs and services. Become familiar with the by-laws, policies, and procedures of the Consortium. Continually work to promote the Consortium mission.
2. Work to attract new members who can make significant contributions to the work of the Consortium and reflect the diversity of the community and the HIV/AIDS epidemic.
3. Prepare for and participate in Consortium meetings. Consider serving on a Consortium committee. Consider serving in leadership positions, if you meet qualifications and are nominated or selected.
4. Avoid prejudiced judgments on the basis of information received from individuals and urge those with grievances to follow established policies and procedures for grievances within the Consortium.
5. Bring a sense of humor and a positive attitude to the Consortium work.6. Be an active Partnership member by attending all Partnership and committee meetings.

Meeting Guidelines

1. Maintain confidentiality of Consortium and Steering Committee meetings and speak for the Consortium only when authorized to do so.
2. I understand that my participation becomes a matter of public record, pursuant to Tennessee Open Meetings Act, 1974 Public Acts, Chapter 442.
3. If I self-disclose my HIV status, it may be used for the consortium nominating process or in consortium documentation to help ensure PIR (parity, inclusion and representation). This documentation may be named-based.

Avoiding Conflicts

1. Avoid even the appearance of a conflict of interest that might embarrass the Consortium and jeopardize the credibility of the grantmaking and allocations process and disclose any possible conflict to the Consortium in a timely fashion.
2. Maintain independence and objectivity and do what a sense of fairness, ethics and personal integrity dictate even though not necessarily obliged to do so by law.
3. Never accept (or offer) favors or gifts from (or to) anyone who is funded by the Consortium.

Fiduciary Responsibilities

1. Exercise prudence with the Consortium decisions regarding allocation of the Ryan White Part B funds. We are the stewards of these public funds and our decisions about how to spend them must be made in a fair, impartial and informed way.
2. Serve the HIV/AIDS community as a whole rather than serve a special interest group, constituency or service provider. (It is very important that all various perspectives of the HIV/AIDS epidemic be represented and participates in discussions. Ultimately, all Consortium members need to make final decisions for the good of the entire community.)

Zero Tolerance Policy

United Way of Metropolitan Nashville has a zero tolerance for unlawful harassment toward our employees, volunteers, or applicants. Volunteers who refuse to engage in or tolerate in others any form of harassment including, but not limited to, inappropriate comments/jokes or other physical, verbal or graphic conduct with relationship to a person's disability, age, race, color, sex, religion, sexual orientation, gender identity, national origin or citizenship. In addition, volunteers will not engage in or tolerate in other unwelcome sexual advances or other verbal or physical conduct of a sexual nature towards, volunteers, or applicants. Any volunteer found in violation of this policy may be asked to resign from his/her volunteer position.

Waiver

The names of volunteers affiliated with the Consortium of Ryan White HIV/AIDS Program, may be included in agency created documents (e.g., annual report, volunteer recognition materials, media publications, etc.). Due to issues of public disclosure, members may waive the listing of their names in United Way of Metropolitan Nashville publications.I agree to allow the use of my name or image in publications of United Way of Metropolitan Nashville.

Electronic Signature

I, ______, have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge.I also certify that:I understand the questions and statements on this application.I have read and understand the legal information.I understand the penalties for giving false information or breaking the rules.I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.