Aging Texas Well Advisory Committee
Application for Advisory Committee Membership
If you would like to apply to be a member of the Aging Texas Well Advisory Committee, please fill out this application. The committee will advise and make recommendations to the Health and Human Services Commission and state leadership on implementation of the Aging Texas Well Initiative.
If a question does not apply to you, enter “N/A.”
HHSC will use the information you put on this application and your resumè to decide if you’re eligible to serve on this committee.
Important note: Committee members aren’t paid to attend or travel to committee meetings.
HHSC won’t consider an application received after June 1.
SECTION 1 - Personal Information
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Name:
Home Address:
City: State: TXZIP: Phone:
Fax: Email:
Employment Information
Business/Organization:
Address:
City: State: TXZIP: Phone:
Fax: Email:
Current Position Title:
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Please check where you would like to receive further communications:
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Work Email Home Email Work Address Home Address
Application
New/Initial ApplicationRenewal Application
Gender
MaleFemale
Race/Ethnicity
American Indian/Alaskan Native Asian/Pacific Islander
Black Hispanic
White Other
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SECTION 2 (Older Person/Family/Caregiver Applicants Only)
An older person who may be affected by issues related to aging may apply to be on this committee. A family member, or caregiver, of a person affected by issues related to aging may apply to be on this committee. A "family member" may be the caregiver, spouse, guardian, child or adult sibling of a person who may be affected by issues related to aging.
Please complete SECTION 2 only if you are an older person affected by issues related to aging, a family member or a caregiver.
Please tell us about your direct experience with older adult service providers and/or knowledge of issues impacting older adults.
Please tell us why you want to serve on this committee.
SECTION 3 (Professional Applicants Only)
A professional may apply to be on this committee. Professional applicants include: providers; professional associations; non-profit organizations; managed care organizations and other subject matter experts.
Please complete SECTION 3 only if you are a professional applicant. You are required to attach a resumè or certification.
Describe your direct knowledge and perspectives of issues impacting older Texans and the complexities of these shifting demographics.
Explain why you are interested in serving on this committee.
List your relevant personal and professional achievements, including current licensures and activities that address contributions you could make to the committee:
Have you ever been disciplined by any licensing board or professional or civic organization, including the HHSC Inspector General?
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YesNo
If yes, please explain:
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SECTION 4 (ALL applicants must complete this section.)
State law and committee Bylaws requires that The Aging Texas Well Advisory Committee include at least one person to represent the following category. Please check the category you would like to apply for.
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Aging Disability Resource Center representative
Member Participation
Every member appointed to the Aging Texas Well Advisory Committee must attend regularly and must participate in subcommittee activities, projects and presentations.
- Regular committee meetings are held about once every three months. The presiding officer may also call a special committee meeting. Members must travel to Austin, Texas or participate by phone for these meetings. Each meeting may last several hours.
- Please note: Committee members won’t receive compensation (stipend) or reimbursement of expenses for participation on the committee.
Do you believe you will be able to regularly participate in the Aging Texas Well Advisory Committee activities, if you are appointed?
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YesNo
If no, please explain:
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Have you served, or are you currently serving, on other advisory committees, councils or workgroups? If so, please list the name of the group, its charge and your role.
Miscellaneous Information
Do you have a personal or private interest in a matter pending before HHSC? ("Personal or private interest" means you have a direct monetary interest in the matter or owe your loyalty to an entity involved, but does not include the member's engagement in a profession, trade, or occupation when the member's interest is the same as all others similarly engaged in the profession, trade or occupation.)
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YesNo
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Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)?
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YesNo
If yes, please explain:
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References
Please provide the names and contact information for two people who can tell us more about your qualifications to serve on the committee. References can include employers, clients, religious leaders, community leaders, advocates, friends or others who know about your interest in and/or involvement with service delivery through Medicaid. If you are applying as a provider, include at least one client reference.
Reference #1
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Name:
Address:
City: State: ZIP:
Daytime Phone:
Email:
Relationship (how this person knows you):
Reference #2
Name:
Address:
City: State: ZIP:
Daytime Phone:
Email:
Relationship (how this person knows you):
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All the information contained in this application is true and correct. I understand that the committee will meet in Austin, Texas at least four times per year. If selected, I will make every effort to attend all committee meetings.
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Signature (typed name is acceptable)Date
Please return this form and any supporting documentation to:
Email: Holly
Attn: Holly Riley
Mail: Texas Health and Human Services Commission
701 W 51st St., Mail Code W-616
Austin, Texas 78751
Attn: Holly Riley
Fax: 512-438-4829
Attn: Holly Riley
If you have any questions about the application or the Aging Texas Well Advisory Committee, please contact Holly Riley at 512-438-4293 or by email at .
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