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2. Description

   THE DEADLINE FOR APPLICATION IS CLOSED. If you still wish to apply, your application will be reviewed by the Taskforce who will reach out to you based on current needs.

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   The Montgomery County Homelessness Taskforce is seeking volunteer members to serve as part of a time limited and solutions-oriented team. The taskforce will review data trends, outcomes of existing interventions, and new evidence-based interventions. The goal is to effectively address the whole person including employment, housing, and supportive services.

   The task force will be comprised of people who represent service providers, landlords, developers, schools, courts, housing, local officials, municipalities, faith-based organizations, and those with lived experience.
   
   This application seeks people who work at provider agencies and those with lived experience to apply.
   
   The deadline to apply is Friday, April 7, 2023.

   The County will use the demographic information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. Your responses will not be disclosed in identifiable form without your informed consent.

4. First Name*
5. Last Name*
7. Home Address 1*
9. Home Address 2
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Email Address*
18. Employment: Company or Business Name
20. Work Address 1
22. Work Address 2
24. Work Phone Number
25. Work Email
27. Preferred Method of Contact
    -- Select One --Personal Phone NumberPersonal EmailWork PhoneWork Email
28. Best Time To Be Contacted
30. Gender (Check all that apply)

    1. Female
    2. Male
    3. Non-binary, transgender, or another gender
    4. Prefer not to answer
31. If your identity is not listed, please use this box to describe it.
33. Race/Ethnicity
    -- Select One --Latino/HispanicWhite alone, non-Latino/HispanicBlack or African American alone, non-Latino/HispanicAmerican Indian and Alaska Native alone, non-Latino/HispanicAsian alone, non-Latino/HispanicNative Hawaiian and Other Pacific Islander alone, non-Latino/HispanicMultiracial, non-Latino/Hispanic
34. Do you self-identify with any of the following communities?

    1. Person with a disability
    2. Veteran
    3. LGBTQIA+
36. Age Range
    -- Select One --18 - 29 years old30 - 45 years old46 - 55 years oldOver 55 years old
37. Do you represent any of the following areas?*

    1. Providers of services to homeless individuals (e.g. behavioral health, shelter, physical health).
    2. Montgomery County residents with lived experience (not currently homeless but experienced homelessness in the past 5 years).
    3. Other
39. Please attach your resume or bio here. If you don't have either of these, you may use the space below to summarize your relevant experience.
41. If you don't have a resume, please provide a brief statement about work you have done relevant to the Homelessness Taskforce.
43. In a few sentences, please briefly why you are interested in joining the Homelessness Taskforce. Please indicate how you feel you will represent the Board and bring a unique/diverse perspective.
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit Submit and Print

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