Camden Coalition Community Advisory Committee

Camden Coalition Community Advisory Committee

MEMBERSHIP APPLICATION FORM
The Community Advisory Committee (CAC) is a group established by the Camden Coalition Board of Directions to advise and make independent recommendations on the strategic direction of the organization. The CAC will help the Camden Coalition remain responsive to community health needs of residents of the City of Camden. The CAC is intended to enable consumers, which will comprise a majority of the CAC, to take an active role in improving their own health and that of their family and community members.

Members of the CAC will be recruited to represent the diversity of the community including race/ethnicity, age, gender identity, sexual orientation, disability, and geographic location, should possess a collaborative working style, and provide expertise and insight in the area of mental health, addictions, wellness promotion, education, housing, seniors services, culturally specific health services, children and youth services, corrections and public safety, disability services and health disparities. Individuals with a broad community perspective on health matters will be preferred.

All meetings will take place on a hybrid schedule (online or in-person) one per month at 5:30pm. The CAC is seeking those who can commit 3 to 6 hours per month to attend monthly meetings and or/special events.

All information provided in this application is confidential and will only be used to ensure that the CAC is reflective of the diversity of Camden.
Name

First NameLast Name
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if not the same as home address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which municipality in Camden County do you live in?
What neighborhood in Camden do you live in? (if applicable)
Race/ethnicity (optional)

American Indian/Alaska NativeAsian/Pacific IslanderBlackHispanicWhiteOther
Gender (optional)
I identify as (check all that apply):
What is your age?
I have personal experience or have cared for a loved one who has experienced the following Check all that apply.
Do you have any special skills or experiences that you would like to contribute to the CAC? Check all that apply.

Advocacy on behalf of self or othersConnecting personal experience to common/shared challengesCoordinating group activitiesCreative thinkingInviting others to joinListening to the concerns and experiences of othersMaking a step-by-step planMeeting facilitationNetworking with othersPlanning a meeting or gatheringProblem-solvingPromoting an open and safe space to share ideas when working in a groupPublic speakingSharing complex ideas in simple waysTaking notesTeaching or trainingTechnology is easy for meTuring ideas into actionUnderstanding other' perspectivesOther
Do you have any interest in the following topics? Check all that apply.

AddictionAdvocacy & ActivismCriminal JusticeDisability RightsEducation & Youth EngagementFamily Reunification & SupportFood Insecurity & AccessGun ViolenceHIV/AIDSHomelessnessLeadership DevelopmentMental & Behavioral HealthPeer Mentor/EducationResearchSharing my story to influence changeTransportation BarriersOther
What do you hope to gain from becoming a member of the CAC?
Would you need translation services to participate in CAC meetings?

YesNo
Should be Empty: