Continuum of Care Annual Membership Form

As a Guilford County Continuum of Care (CoC) member, thank you for your continued commitment to preventing and ending homelessness in Guilford County. In order to remain in good standing, as well as to ensure that the Continuum of Care has the most current information for each member, we are requesting that the following form be completed on an annual basis. Voting membership also requires execution of the Conflict of Interest Disclosure Policy, which is included at the end of this form.

Members of the Continuum of Care will retain their membership and voting status as long as they are in good standing. To remain in good standing, Voting Members must attend 75% of the regularly scheduled CoC Membership Meetings within a calendar year. Attendance at meetings is tracked on an individual basis, not at the agency/organization level. Therefore, for a Voting Member of an agency/organization to remain in good standing, they must attend at least 75% of the meetings.

Recognition as a Voting Member of the Continuum of Care allows participation in the overall strategy and direction for ending homelessness in Guilford County. Members are listed on the CoC website, have opportunities for funding, receive biweekly newsletters, and have access to training opportunities. If you have any questions, please email infoCoC@guilfordcountync.gov.

Member Information

I am a member of the CoC at the following level: Value is not selected

Name of Organization or Individual

Mailing Address

Physical Address (if different than mailing address)

Main Phone

Fax

Website

Primary Geographic Area Served by Organization or Individual

Mission/Purpose of Organization or Individual

Population(s) Served by Organization or Individual

Type of Organization or Entity (click and select all that apply) Values are not selected

What services and/or programs do you offer as an organization or individual?

President / Executive Director

First Name

Last Name

Phone Number

Email

Current Board Chair

First Name

Last Name

Phone Number

Email

Voting Representatives

Each member may name up to two (2) voting representatives. Only one (1) representative of an agency/organization may cast a vote on each action. In the event that neither representative can attend a duly called meeting, he or she may, with prior notice to the Chair, designate a proxy. Designations of proxies to conduct business should be rare. If a Continuum of Care voting member is unable to routinely conduct business, the agency/organization should seek to assign representation to another individual.

Voting Representative #1

First Name

Last Name

Representative Title

Email

Phone

Voting Representative #2

First Name

Last Name

Representative Title

Email

Phone

Continuum of Care Participation and Funding

Does your organization receive funding from the U.S. Department of Housing and Urban Development? (Select all applicable fields.) Values are not selected

Does your organization participate in the Coordinated Entry process (e.g. Assess presenting individuals/households, refer individuals/households to Coordinated Entry Access Points, receive referrals from Coordinated Entry, attend weekly Coordinated Entry Case Conferencing meetings, etc.) ? (Select all applicable fields.) Values are not selected

Does your organization enter data into the Homeless Management Information System (HMIS) or an HMIS-comparable database? Value is not selected

If no, is your organization interested in utilizing HMIS or an HMIS-comparable database? Value is not selected

Do you or a representative from your organization participate on the Continuum of Care Board and/or Committee(s)? Values are not selected

List Committee (s) here that you or a representative from your organization participate on .

If you are not currently serving on a committee, please select the committee(s) and/or workgroup(s) in which you would be interested in serving below. (Select all that apply.) Values are not selected

Click HERE to learn more about each committee.

Conflict of Interest Disclosure Policy

ACKNOWLEDGMENT AND DISCLOSURE STATEMENT

The undersigned person, who has been appointed or elected to serve the Guilford County Continuum of Care in the capacity reflected below, hereby confirms that the undersigned has read and does understand the Guilford County Continuum of Care’s Conflict of Interest Policy as outlined in the Guilford County Continuum of Care Governance Charter and has received a copy of that Charter for present and future reference.

The undersigned agrees to take appropriate action with respect thereto, including initiative in disclosing activities, interests, or relationships wherever an actual or potential conflict of interest may exist, and to otherwise comply in all respects with the Conflicts of Interest Policy.

Consistent with the foregoing, the undersigned makes the following disclosure of any and all Interests as defined in the Conflicts of Interest Policy, in accordance with applicable reporting responsibilities (if none, please write “NONE”):

Disclosed Interests

First Name

Last Name

Position

Applicant Email

Date

Signature

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Continuum of Care - Annual Membership Form

Member Information

President / Executive Director

Current Board Chair

Voting Representatives

Continuum of Care Participation and Funding

Conflict of Interest Disclosure Policy