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Community Engagement Council

Advocates • Allies • Advisors

The Community Engagement Council will strive to inform, educate, and advocate on behalf of those impacted by HIV.

If you are interested in learning more, please complete this interest form.

Contact Information

First Name(*)

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Last Name(*)

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Preferred/Chosen Name

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Pronouns

He/Him/His

She/Her/Hers

They/Them/Theirs

I use a different set of pronouns

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Share your pronouns with us.

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Phone Number(*)

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Is this your cell, home, or work number?(*)

Cell

Home

Work

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E-mail Address(*)

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What are the best ways to reach you?

I agree to receive communication about the Community Engagement Council through:(*)

Phone Call

Text Message

E-mail

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Is it OK to leave a voicemail related to the CEC?

Yes

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Would you like to receive e-mails about upcoming clinic events that serve our community?

Yes

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Community Affiliation
Your responses will be kept private and confidential.

How are you connected to our Community?

PWH (Person with HIV)

Research Participant at 1917 Clinic (clinical or behavioral)

PrEP (Pre-Exposure Prophylaxis) Client at 1917 Clinic

Clinic Volunteer

Community Partner with Shared Clients

Routinely attend Clinic events

Other involvement at 1917 Clinic

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Do you receive healthcare services at the 1917 Clinic?

Yes

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How long have you received services at 1917 Clinic?

Less than 2 years

2 - 5 Years

5 - 10 Years

More than 10 Years

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Please describe your involvement with the 1917 Clinic.

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Availability
The Community Engagement Council will meet routinely (possibly monthly). We will set a date and time that works for all members. Council members will also have the opportunity to serve on other clinic teams that meet during clinic hours.

Please indicate your general availability to attend meetings.

What days of the week are you generally available to attend meetings?

What time of day are you generally available to attend meetings?

Morning (8AM to 12PM)

Lunchtime (12PM to 1PM)

Afternoon (1PM to 5PM)

Evening (5PM to 8PM)

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Skills and Interests

What else are you skilled or interested in?

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Please explain why you would like to join the Community Engagement Council (CEC)?(*)

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Thank you for completing this form and providing us your information!

Click the Submit button below to send your information to the Community Engagement Team. You will also receive a confirmation e-mail that your form has been successfully submitted.

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Community Engagement Council Interest Form