ADVISORY GROUP APPLICATION First Name Last Name Address Email Phone Organization Name (if applicable) Job Title (if applicable) 1. Which sector or category do you fulfill? (check all that apply)At LargeBehavioral Health ProviderCity of Seattle GovernmentCommunity-Based OrganizationCommunity-Based Organization Serving Criminal Justice Involved IndividualsConsumer / Community CoalitionCorporate / Philanthropic Foundation or Community BenefitCowlitz TribeDuwamish TribeFederally Recognized Health CenterFirst ResponderHospital / Health SystemInformation and Referral ProviderKing County GovernmentMedicaid Managed Care OrganizationMuckleshoot TribeIndigenous Serving / Led Community-Based OrganizationOrganizational SponsorPrivate InsurerSocial Service Support or Delivery OrganizationSnoqualmie TribeSuburban Area GovernmentTribal Community MemberTribal Data SpecialistUrban Indian Health BoardOther (Please specify below) Please specify 2. Why do you want to serve on the Connect2 Community Network’s Advisory Group? Why is a Community Information Exchange in King County important? 3. Please describe your commitment to and experience with advancing health equity and supporting anti-racism practices. 4. Please describe your experience working with multiple organizations and/or across sectors to deliver outcomes for people and communities. 5. What personal experiences, skills, or qualifications do you have that would help you be successful in this role?
