“The Miami-Dade Community Based Care Alliance exists to design, strengthen, and oversee a cohesive system of care that will ensure the safety and well-being of children in a manner that is family centered, community based, integrated, outcome oriented, culturally competent, timely in its responses, and accountable.”

Membership Application

We appreciate your interest in serving as a member of the Miami-Dade Community Based Care Alliance (CBC Alliance). Please review the attached Membership Information and then complete the following questions. Send /fax the completed application and your CV to Candice Maze, Executive Director, Community Based Care Alliance, 401 NW 2nd Ave. S-926C, Miami, Florida 33128. Fax (305) 349-1424.

Name:__________________________________________________________________

Address:________________________________________________________________

Occupation:_____________________________ Telephone: ______________________

Place of

Employment:____________________________________________________________

Email:__________________________________________________________________

Areas of Expertise (please check all that apply):

__accounting __management/business

__health __mental health

__advertising/PR __legal

__education __lobbying

__community relations __child welfare

__others (specify)___________________________________________________Miami-Dade

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The following questions regarding race/ethnicity will help the CBC Alliance to

ensure the diversity of it membership. Please check one:

__White, non-Hispanic __African American __Caribbean __Asian

__Hispanic/Latino __Haitian __American Indian ___ Other: ____________

Country of Origin____________________ Language/s: ____________________

Please explain why you are interested in serving as a CBC Alliance member:

________________________________________________________________________

Membership on the CBC Alliance requires a two to three-year obligation and a significant time commitment that includes, but is not limited to, attendance at monthly CBC Alliance meetings, active participation in CBC Alliance events and committees and advocacy on behalf of the CBC Alliance in the community. CBC Alliance members will be excused from service should they have more than three unexcused absences from the regularly scheduled monthly CBC Alliance meetings.

Pursuant to Florida law, CBC Alliance members may not receive funding from or work for any organization that receive funds from the Department of Children & Families or Our Kids, Inc. (Florida Statute 20.19(6)(f)).

By signing below, I acknowledge that I have read the attached Membership Information and, if elected to the CBC Alliance, I will fully assume the responsibilities and obligations of a CBC Alliance Member.

_________________________________ ______________

Signature Date

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