Application for Planning Council Membership

The Middlesex-Somerset-Hunterdon Transitional Grant Area Ryan White Part A HIV/AIDS Health Services Planning Council is a federally mandated community group appointed by the Board of Commissioners of Middlesex County, New Jersey, to plan the organization and delivery of Ryan White Part A HIV/AIDS services.

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To the greatest extent possible, all information that is provided in this application will be kept confidential. It will be viewed by the Recipient, Ryan White Program Staff, and the Membership & Bylaws Committee of the Planning Council as needed during the nomination/selection process. Directions: Please read this form carefully and complete all information with the best of your knowledge.

Personal Information

First Name *

Last Name *

Birthday

Address

Email *

Confirm Email *

Home Phone

Cell Phone

Best Time to Call

Are you currently employed?

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On which of the following mailing lists (via email) would you like to be included?

Planning Council (usually 1st Tuesday of each month 6-8pm)Quality Improvement and Strategic Planning (every other month-3rd Tuesday 2-4pm)Membership & Bylaws Committee (3rd Wednesday of each month 1-2pm)Mentorship & Outreach (every other month- 2nd Wednesday 6-8pm)