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2023 Community Advisory Board Application
2023 Community Advisory Board Application
Hi there, please continue on to begin filling out this form. This may take 10-15 minutes to complete. If you submit an email, you will receive a verification email confirming that your application has been received. 
2023 Community Advisory Board Application
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    Purpose: To have a group of approximately 7-12 clients/patients responsible for holding Corktown Health accountable to fulfilling their mission and providing quality services. The CAB will evaluate the services provided by Corktown Health and respond to clients’ suggestions and concerns about the services that they receive. To have a group of approximately 7-12 clients/patients responsible for holding Corktown Health accountable to fulfilling their mission and providing quality services. The CAB will evaluate the services provided by Corktown Health and respond to clients’ suggestions and concerns about the services that they receive.  

    Requirements:

    1. You must currently receive/or have received a service at Corktown Health in the past two years.
    2. You must be able to attend a late afternoon meeting on the third Tuesday of each month.
    3. A one year commitment will be expected for joining members.
    4. The meeting will be held via Microsoft Teams. Technology use (WIFI on a phone/computer/laptop/tablet) is required.
    5. Orientation will be provided to each new member.

    Incentives: You will be provided with a meal, bus ticket or compensation for gas (if the meeting is in-person), and the good feeling from advocating for clients and improving the services at Corktown Health. There will also be opportunities for various trainings and skill building activities. 

    Directions: Please answer the following questions in detail, as your responses will help to ensure that we have a diverse group of board members who will provide a wealth of experience and wisdom.

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    The folowing information requested is optional and will be kept confidential. All applications will be maintained according to HIPPA regulations regarding Personal Health Information. Providing this information will help us to ensure we have a Client Advisory Board that reflects the diverse populations that we serve.

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    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    Please select the appropriate response.
    • Please select the appropriate response.
    • YES
    • NO
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    Please select any applicable services.
    • Medical Case Management
    • Behavioral Health Services
    • Emergency Financial Assistance
    • Non-Medical Case Management
    • Insurance Assistance
    • Tobacco Cessation
    • Corktown Grows
    • HIV Primary Care
    • Early Intervention Services
    • Medical Nutritional Therapy
    • Food Bank
    • Housing Services
    • PrEP & Prevention Services
    • Keep It Movin' Fitness and Nutrition Services
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    Thank you for completing this application. A CAB member will be calling you soon. If you have not been reached after 14 days, contact a staff liaison by calling Corktown Health Center at 313-832-3300 and ask to be transferred. Thank you so much for your interest in joining the CAB

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