CAC Membership Applic Form English FILL ONLINE

This form is for community members who may want to serve on the Community Advisory Council (CAC)

The Community Advisory Council (CAC) is a committee of the Columbia Gorge Health Council (CGHC). This Health Council governs the Columbia Gorge Coordinated Care Organization (CCO). The CCO is also known as the Oregon Health Plan, or OHP.

The CAC guides the CGHC to respond to the needs of people on the Oregon Health Plan in Hood River and Wasco Counties. It also makes sure the CGHC responds to the needs of the whole community.

Why might I want to serve on the CAC?

When you serve on the CAC, you contribute to making our community better for all, most of all for people on OHP. You can also learn and grow as a leader. You will have a chance to advocate for solutions that support health and well-being in the region.

What would I do as a CAC member?

Make sure the CCO stays focused on the community by sharing your opinions and advice
Talk about your experiences getting care and help find ways to make the care better
Suggest how to improve the health care and services in the Gorge
Oversee the Gorge Regional Community Health Assessment and Community Health Improvement Plan

How much time would it take?

Once a month you would attend one meeting for two hours. There is no meeting in July. One month the meeting is in The Dalles and the other month it is in Hood River. Because of COVID-19, we are currently only on Zoom until further notice.
You would commit to attend at least 6 of the meetings per year for 2 years.

What kind of support do you offer CAC members?

We value the input of CAC members. To thank and support them we offer:

A $50 stipend each meeting
Transportation and childcare support as needed
Interpretation

Do you have questions? Would you like help filling out this form? If so, please call or email Katy at 971-300-4421, katy@gorgehealthcouncil.org

First Name

Last Name

Phone

Format: (000) 000-0000.

Email (if you have one)

example@example.com

Street Address

City

Zip

Date of Birth

Date

County

Organization or Employer (if that is who you would represent)

1- - What is your gender identity?

Do you identify as having a disability?

With which racial or ethnic groups do you identify? (Check all that apply.)

4- This is how long I have been an Oregon Health Plan (OHP) member:

5- Please check all that apply:

6- Would you need transportation, interpretation, childcare support or any other support? If so, please explain what help you would need

Please tell us about yourself. Please write about your background and if you have been a part of other community meetings or advisory councils. Attach one more page if needed.

Please tell us why you want to be a part of the CAC.

Please list two or three people below who can tell us about you.

1) First & Last Name. Organization or Employer (if applies). Phone or Emailil

2) First & Last Name. Organization or Employer (if applies). Phone or Email

3) First & Last Name. Organization or Employer (if applies). Phone or Email

I swear that what is written on this form is true and correct to the best of my knowledge and belief. If I am invited, I agree to serve on the CGHC Community Advisory Council for two years. I will attend and participate in at least six meetings a year and other sub-committee meetings as needed. If I am not able to attend, I will call or email the CGHC staff before the meeting.

Signature

Date

Please note that if you fill out this form, it does not make you a CAC member. The CAC Selection Committee will choose members to make sure people from all over Hood River and Wasco Counties have a voice at this table.

If we are not able to invite you to be a CAC member, can we contact you to be a part of other CGHC activities in the future?

Thank you for applying! We will get back to you in less than 2 weeks to let you know about your application.

Columbia Gorge Health Council Community Advisory Council Membership