Membership Application 2023 KS BoS CoC Membership Application Membership to the Kansas Balance of State Continuum of Care (CoC) is open and free to all parties who support the mission of the CoC as described in the CoC’s Governance Charter. Organizations and unaffiliated individuals residing or working within or providing services within the KS BoS geography may be members of the CoC. The three types of membership are described below. Each person applying for membership can only apply for one of the membership types described below. General Membership: General membership is open to any individual, whether or not they are affiliated with an organization. Multiple individuals affiliated with the same organization may participate in general membership. Voting Membership (Organizational Representative): Organizational affiliation is defined as being an employee or board member of an organization. Voting membership of the CoC shall be limited to only one voting member per organization, to ensure that no organization has more representation or input than another. Organizations may designate a primary and alternate voting representative. Organizations can have multiple representatives actively participate in CoC general membership, but only one person per organization may be a voting member. Voting Membership (Unaffiliated Individual): Individuals who are not affiliated with a represented organization may apply for an individual membership. Individuals that are affiliated as employees or board members with a member organization are not permitted to be unaffiliated individual voting members but may apply for general membership.Name(Required) First Last Birthdate(Required) Month Day Year Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) PhoneGender Identification(Required) Female Male A gender other than singularly female or male (e.g., nonbinary, genderfluid, agender, culturally specific gender) Transgender Questioning Other Race(Required) American Indian, Alaska Native, or Indigenous Asian or Asian American Black, African American, or African Native Hawaiian or Pacific Islander White Other Ethnicity(Required) Non-Hispanic/Non-Latin(a)(o)(x) Hispanic/Latin(a)(o)(x) Other Please select all stakeholder groups you represent(Required) Service provider working to end homelessness Person who is currently or formerly homeless Federal partners working to end homelessness Local government Philanthropic funders/partners Public Housing Authority Emergency Food and Shelter Program Native and Indigenous Population Interfaith representative Victim Service Provider/Survivor Community Education community Criminal Justice System LGBTQ+ community Organizations serving immigrants and refugees Senior and/or disabled community Youth and/or families community Veteran community State disaster response organization Other Other Stakeholder Groups Please list all organizations that you are a staff or board member of(Required)Please select which type of membership you are applying for. General Membership (Non-Voting Member) Organizational Representative (Voting Member) Unaffiliated Member (Voting Member) See top of form for descriptions.If applying for organizational representative, enter the name of the organization If applying for organizational representative, enter the name, phone, and email of primary representative who will have the authority to vote as a representative of the organization.If applying for organizational representative, enter the name, phone, and email for secondary representative who may only vote when the primary representative is unavailable.Please indicate the Region(s) you serve Region 1 - Northwest Region Region 2 - Southwest Region Region 3 - North Central Region Region 4 - South Central Region Region 5 - Northeast Region Region 6 - Lawrence/Douglas County Region 7 - East Central Region Region 8 - Southeast Region Region 9 - Flint Hills Region Please check if you are interested in serving on any of the following CoC committees (check all that apply): Nominations and Membership Committee: Reviews Steering Committee applications and actively recruits diverse stakeholders. Performance and Compliance Committee: Determines funding priorities and rank and review process. Develops performance goals and monitoring protocols for CoC Program. Individuals affiliated with homeless service agencies receiving or requesting CoC Program funding are prohibited from participating in the committee. Equity Committee: Establish and pursue CoC-wide goals related to equity. in coordination with other committees, HMIS lead, and Collaborative Applicant HMIS Committee: Establishes policies, procedures, and protocols for functions essential to the viability and success of the HMIS, including data quality, reporting, and data sharing protocols. Coordinated Entry Committee: Develops CE policies and procedures to be reviewed and approved by the Steering Committee. Facilitates case conferencing and responds to client grievances. Signature(Required)Signature Date(Required) MM slash DD slash YYYY Office 2001 Haskell AvenueLawrence, KS 66046 Contact Us staff@kshomeless.com(785) 764-8838 Subscribe For Updates & Free Resources Success! Email Subscribe Translate FollowFollowFollow
