Maryland PRIDE in Health Steering Committee Membership Application

Thank you for your interest in becoming a member of the PRIDE in Health Steering Committee. Please
complete this brief application. You will receive a follow up contact for an interview where you will also
have an opportunity to ask questions and learn more about this opportunity. If you have any difficulty
with this form or need assistance completing it, please contact Jean-Michel Brevelle at 443-301-4681between 9:00am and 5:30pm, Monday through Friday.

Name (First, Middle, Last) *
Home Street Address *
Unit/Apt/Floor
City *
State *
Zip Code *
Region of Primary Residence *
Phone Number *
Email Address *
What is your gender? *
Check as many are true for you
Required
What sex were you assigned at birth? *
Check one
How do you describe your sexual orientation? *
Select all that apply.
Required
Do you consider yourself to be Hispanic/Latino/Latinx? *
Select all that apply.
Race *
Select all that apply.
Required
Age *
Which Unit of the Steering Committee are you applying for? *
Tell us briefly about your experience with substance abuse treatment/recovery and/or housing. *
Tell us why you would like to be a member of the PRIDE in Health Steering Committee. *
Tell us briefly about the skills you will bring to the Steering Committee. *
Do you have access to a computer or tablet?
Check all that apply
How do you usually connect to the Internet? *
Check all that apply
Required
Do you have a stable telephone number? *
Check all that are true for you
Required
How do you usually get from one place to another? *
Check all that are true for you
Required
Do you have any accessibility needs? *
Check all that are true for you
Required
When would you be able to attend meetings?
Check all that are true for you
Online Meetings
In-Person Meetings
Weekday Mornings (9:00-11:30am)
Weekday Afternoons (12:00-5:00pm)
Weekday Evenings (6:00-8:30pm)
Weekend Mornings (9:00-11:30am)
Weekend Afternoons (12:00-5:00pm)
Weekend Evenings (6:00-8:30pm)
Additional Questions or Comments
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