Section 1: About You

Name
Home Address
Preferred phone type:
Preferred communication method:

Section 2: Tell Us About Yourself

Tell us about your experience, skills, education, work, or lived experience that would help you contribute. If applicable, include your experience with or knowledge of One Care.
Tell us about your experience working with, supporting, or engaging people or communities.
Describe your experience working with people from different backgrounds or communities. This may include people with disabilities, Deaf or Hard of Hearing communities, blind or visually impaired people, LGBTQ+ communities, people experiencing homelessness, or other populations. We welcome a wide range of experiences and perspectives.

Section 3: Which Best Describes You?

Criterion 1: MassHealth Member or Family Member
If applicable, check all that apply:
Criterion 2A: Community-Based or Consumer Advocacy Organization
Criterion 2B: Provider or Trade Association
Provider Type:

Do you receive compensation from this organization?
Populations served (check all that apply):

Section 4: Geographic Representation

Where do you live or work? Check all Massachusetts counties you know well.

Public Records Notice

In submitting this application, you understand that information provided, including any voluntary self-identification as a recipient of MassHealth or Medicare coverage, may be subject to the Massachusetts Public Records Law.
Consent
Date