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MEMBERSHIP APPLICATION PHILADELPHIA HIV PREVENTION PLANNING GROUP (HPG) CITY OF PHILADELPHIA
Applications are accepted on a rolling basis throughout the year. The City of Philadelphia will appoint new members annually for terms of one or two years beginning each July 1.  Membership on the HIV Prevention Planning Group is a volunteer position with the City of Philadelphia.

Membership entails a time commitment of between four (4) and eight (8) hours per month.  By completing and submitting this application, Applicants attest to the availability of this amount of time, per month, and acknowledge their understanding of this responsibility.

The HIV Prevention Planning Group’s membership collectively represents Philadelphia’s diverse communities affected by HIV disease.  Applicants are asked to provide personal demographic information and past experience in order to achieve the Group’s mandates for inclusion, representation, and parity.

In addition to the information collected below, Applicants should also include the following:
(1) A brief resumé or biographical summary, and
(2) A personal written statement describing the Applicant’s primary reasons for seeking membership on the HIV Planning Group and other pertinent information, including any time constraints or preferred term lengths.

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PERSONAL INFORMATION
Full name: *
Home address: *
City: *
State: *
ZIP code: *
Primary phone: *
Secondary phone:
Email: *
Employer:
Employer City:
Employer State:
Term length preference:
EMERGENCY CONTACT INFORMATION
Name of person to contact in case of an emergency: *
Relationship to applicant: *
Emergency contact primary phone: *
Emergency contact secondary phone: *
Emergency contact email: *
DEMOGRAPHIC INFORMATION
Age range: *
Gender: *
Risk category : *
(check all that apply, if applicable)
Required
Race : *
(check all that apply, if applicable)
Required
Ethnicity: *
Educational attainment: *
Affiliations, Expertise, and Representation
Please fill in each column below by check-marking all that apply and indicate your affiliations below.
Your affiliations: *
If your response is "Other" please specify; i.e. substance abuse, mental health, corrections, homeless, philanthropy):
Required
From above affiliation choices, indicate your primary affiliation:
Indicate a secondary affiliation:
Your expertise: *
If your response is "Other" please list your expertise
Required
From the above choices, please indicate your primary area of expertise:
Indicate a secondary area of expertise
Your community representation
If your response is "Other" please list your community representation
From above choices, indicate your primary representation
Indicate a secondary representation
AUTHORIZATION
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Signature
Submit your application including this form, brief biographical summary. and personal statement to:
Philadelphia Office of HIV Planning
Attention: HPG Applications
340 North 12th Street, Suite 203
Philadelphia, PA 19107
Tel: 215-574-6760  
Fax: 215-574-6761
Email: HPG@hivphilly.org 
Online: www.hivphilly.org
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