Please submit your completed application and additional materials to:

Arielle Lewis Charlotte AHEC 704.512.6523 phone 704.512.6568 fax arielle.lewis@atriumhealth.org www.charlotteahec.org

Charlotte AHEC Regional Advisory Committee Application Thank you for your interest in applying for membership with the Charlotte Area Health Education Center (CAHEC) Regional Advisory Committee. The committee's role is to gather information on the trends and updates related to community and regional needs impacting health education.

Mission

CAHEC, a division of Atrium Health and part of the NC AHEC Program, strives to fulfill our mission of providing quality educational opportunities and services for all healthcare professionals by building partnerships, promoting recruitment and retention of healthcare professionals, and advancing healthcare quality in the communities we serve.

Vision

To help lead the transformation of health care education and services in North Carolina.

NC Counties Served: Anson, Cabarrus, Cleveland, Gaston, Lincoln, Mecklenburg, Stanly, Union

We appreciate you considering involvement and investing your personal time and energy into this important aspect of building the transformation of healthcare education and services in North Carolina.

We have developed a comprehensive selection process that includes the following:

STEP 1

The CAHEC Regional Advisory Task Force will carefully review and assess all nominations for further consideration.

All interested candidates will need to complete the application in full. Please attach a resume/CV with your application. Applications will be open on September 1, 2019 and must be received electronically by October 31, 2019 at 5:00pm EST.

Please also sign included "Permission to Use Likeness" photo release form.

STEP 2 The CAHEC Regional Advisory Task Force will select the new committee members and send notification of acceptance. Committee members will receive notification of acceptance by December 1, 2019.

CAHEC Regional Advisory Committee Members will serve a two year term, beginning January 1st with the possibility for renewal.

SECTION 1: APPLICANT CONTACT INFORMATION

Name: Credentials:

Address: Phone:

Email Address:

SECTION 2: APPLICATION SNAPSHOT

Age: Gender:

Ethnicity:

Counties Served: (check all that apply)

AnsonCabarrusClevelandGastonLincolnMecklenburgStanlyUnionOther:

Disciplines Served: (check all that apply)

Allied HealthCare ManagementCMEDentalHealth CareersLeadershipLibraryMental HealthNursingPharmacyPractice SupportPublic HealthOther:

SECTION 3: PRIOR EXPERIENCE

Please list any previous and current board/advisory committee experience:

Do you have any personal or business interests that could create a conflict of interest (either real or perceived) if appointed? If so, explain below.

Current employer:

Current organizational affiliations:

SECTION 4: OPEN-ENDED QUESTIONS

What resources/strengths can you bring to the CAHEC Regional Advisory Committee?

List any area(s) of expertise:

Why are you interested in serving on the CAHEC Regional Advisory Committee?

SECTION 5: APPLICANT BIO

Please insert bio below (limit to 200 words or less)

SECTION 6: SIGNATURE

I certify that the statements I have made on this form and all attached statements are true, complete and correct to the best of my knowledge.

*Typing your name works as your signature Date (MM/DD/YYYY)

Permission to Use Likeness

This form gives us permission to use your stories, image, voice, etc. under intellectual property laws. It is separate from the Authorization, which gives us permission to use and disclose your information under patient privacy laws.

I grant Charlotte Area- Health Education Center and its associated organizations such as the North Carolina Area HealthEducation Center lth a perpetual, world-wide, royalty free license and permission torecord, use, disclose, portray, reproduce, broadcast, stream, post, print, and publish my (or the person on whose behalf I am serving as a personal representative, who will be included in the terms “my”, “me”, “mine”, or “I”) likeness, picture, video, information (including that released pursuant to an Authorization), story, quotes, and interview, whether in digital,electronic, paper, print, video, oral, or televised form (“Information”) for Atrium Health’s current or future internal and external marketing, fundraising, public relations, and educational purposes on behalf of Atrium Health (including on behalf of its hospitals, practices, programs, and associated foundations). I understand that such Information will be the exclusive property of Atrium Health, free and clear of any claim on my part and may be used in future video or print projects, in whole or in part.

I understand that I will not be compensated for the permissions, licenses, or use of the Information. I also understand that Atrium Health is only responsible for its own actions, and does not control third parties, including other media outlets. I understand that I can request that production of the recording be stopped at any time during production and I can revokethis Permission before the Information is used. On behalf of myself, my child, our heirs and representatives, I agree to release Atrium Health, their commissioners, directors, officers, and employees, from and against any liability related to their use of the Information.

Signature: Print Name: Date:

Note: If the person lacks legal capacity or is unable to sign, an authorized personal representative may sign this form. Note the relationship/authority if signature is not that of the person (Written Proof May be Requested):

Healthcare Agent/POA Guardian Executor/Administrator/Attorney in Fact Spouse Parent Adult Child Affidavit Next of Kin Other: ______________

Revision 04/18

I grant Charlotte Area Health Education Center (Charlotte AHEC) a perpetual, world-wide, royalty free license and permission to record, use, disclose, portray, reproduce, broadcast, stream, post, print, and publish my(or the person on whose behalf I am serving as a personal representative, who will be included in the terms“my”, “me”, “mine”, or “I”) likeness, picture, video, information (including that released pursuant to an Authorization), story, quotes, and interview, whether in digital, electronic, paper, print, video, oral or televised form (”Information”) for Charlotte AHEC’s current or future internal and external marketing, fundraising, public relations, and educational purposes on behalf of Charlotte AHEC. I understand that such information will be the exlusive property of Charlotte AHEC, free and clear of any claim on my part and may be used in future video or print projects, in whole or in part.

I understand that I will not be compensated for the permissions, licenses, or use of the Information. I also understand that Charlotte AHEC is only responsible for its own actions, and does not control third parties, including other media outlets. I understand that I can request that production of the recording be stopped at any time during production and I can revoke this Permission before the Information is used. On behalf of myself, my child, our heirs and representatives, I agree to release Charlotte AHEC, their commissioners, directors, officers, and employees from and against any liability related to their use of the Information.