Membership Application for The Aliveness Project                              The Aliveness Project Logo

Page 1

Requirements for Membership
In order to become a member at The Aliveness Project, we need:
  1. Completed Membership Application
  2. HIV Verification
  3. Proof of MN Residency

Additionally, it is helpful to have Proof of Health Insurance and Proof of Income.   Please attach this documentation as able in the appropriate places in this application and provide physician information.
Applicant Information








Yes No

Service Coordination


Membership Requirements

The Aliveness Project is a nonprofit organization with services provided by volunteers and staff. All services are free to members. The only requirements are that a person is living with HIV in the state of Minnesota (or additional select counties).  All people who use services provided by The Aliveness Project do so by choice and with the understanding that The Aliveness Project and its volunteers assume no liability in conjunction with services and programs.

Members and guests are expected to adhere to the guidelines stated on the last page of this application. Membership and services provided are a privilege. We expect members and any guests to behave in an appropriate, respectful manner while at The Aliveness Project. Members who violate these guidelines are subject to suspension of their membership and certain services.

Once this application is completed, Member Services will receive the application and review it before processing.  If there is additional information required, we will contact you.   It typically takes between 3-7 business days to process an application depending on what additional documentation is still needed and increased seasonal activity. Upon your application being processed, we will contact you by mail, telephone, or case manager contact with your member number and service information.

If you selected that you do not want to be contacted by mail or telephone, it may be difficult for us to reach you with membership updates.  If this is the case, please reach out to us after one week to check on your membership status.

Page 2

General Demographics









HIV Information




Medical Information



Page 3

Income Statement




Housing Status

Proof of MN Residency
Nutrition Referral


Page 4

Household Members
Spouse/Partner (applicable if living with you)




Children
Please complete the following information for each dependent child (if applicable).

















Emergency Contact





Page 5

Additional Contacts

Case Manager - if you have a case manager, please complete the information below:






Physician - if you are connected to care, please complete the information below:




Verification of Eligibility for Membership

If you have documentation of HIV status, you may upload it here.
  We are able to accept MyChart or patient portal documentation as long as it contains the following: client name, HIV/AIDS diagnosis, date, and physician name. We are also able to accept proof of program HH other a letter from a physician.  We are unable to accept medication lists as a form of verification.  

If you are unable to provide documentation, please complete the information below:

I authorize my physician listed to verify or disclose information that confirms I am HIV positive to The Aliveness Project in order to gain membership and access to services.






For Physician ONLY (to be faxed or e-mailed):

This form is solely to establish eligibility of the applicant stated above to become a member of and to receive services provided by The Aliveness Project.  According to the bylaws of The Aliveness Project, the only requirement for membership is that an individual is HIV-positive living in the state of Minnesota.  This information will be kept confidential along with the applicant's signed membership form.  Thank you for your help. 

I verify that the applicant listed below is HIV-positive and is, therefore, eligible to become a member of The Aliveness Project.






The Aliveness Project Logo
Permissions


By providing my electronic signature below, I authorize the Aliveness Project to contact my emergency contact and follow my preferences chosen above.


Page 6

Member Policies


HIPAA Policy/Client Confidentiality: The Aliveness Project will maintain your personal and demographic information in a confidential manner.  Access to information about the services your receive will be limited to The Aliveness Project staff and to others for whom you have provided written consent to share or discuss your information.  This information will also be maintained in a confidential manner.  You will not be identified or identifiable in any written reports or publications without your written consent.  Consent for The Aliveness Project staff to communicated with other The Aliveness Project staff is automatic if you choose to become a member at The Aliveness Project and staff will ensure those communications stay private. 

By agreeing to participate in programs at The Aliveness Project, you agree to provide information at the time of enrollment and periodically thereafter that will assist in data collection, assessment, and funding for services. For these purposes, personally-identifiable information will be provided to the Minnesota Department of Health (MDH) in accordance with contract agreements; however, The Aliveness Project and MDH will maintain your confidentiality as outlined below at all times.  The goal of this is to make it easier for you to access additional services.  The Minnesota Department of Human Services (DHS) and Hennepin County Ryan White Program will receive aggregate or group data only.  The HIV/AIDS Bureau of the U.S. Department of Health and Human Services Health Resource and Service Administration (HRSA) does receive encrypted client level data that does not identify you by name or include any other identifying personal information.  The data collected and reported to our funders is used to identify the services that individuals living with HIV/AIDS need and use, identify barriers to those services and unmet needs, and evaluate future funding needs. 

The Aliveness Project may also be required by state laws and regulations to release information about you in the following circumstances:
  • If there is a subpoena or a court order mandating us to release your records for use in a court proceeding.
  • If you are threatening to harm another person and you have stated both the identity of the person and the means by which you plan to harm that individual.
  • If you are threatening to seriously harm yourself and have identified a means by which you plan to do so.
  • If you are threatening to commit a serious crime or are suspected of committing a serious crime.
  • If it is suspected that you are being maltreated by a caregiver or are not able to protect yourself from maltreatment.
  • If there is a reason to believe you are abusing or neglecting a child or vulnerable adult.
New Hires & Case Management Clients

The Aliveness Project will follow the "Best Practices" when hiring personnel to be case managers or other service providers that work with confidential, data-sensitive information. Members who were or are currently case managed by an Aliveness Project medical case manager, worked with Outreach and Prevention, or a nutritionist cannot become employees of those programs prior to at least one year separation from those services or at the discretion of the Executive Director. Current members that are employees cannot be case managed or receive other services in a data-sensitive category at The Aliveness Project or have access to the Personal Medical Information of other clients.  Anyone already in a dual-role position at the date of this policy was enacted (03/27/2014) will be exempt from this policy.

Client Bill of Rights

Any client/member of The Aliveness Project is entitled to the following rights:
  • The right to treatment with dignity and respect in a nonjudgmental manner, regardless of HIV status, race, ethnicity, age, sex, gender, sexual orientation, religion, country of origin, or physical/mental disability.
  • The right to keep one's HIV status and other personal information confidential, information will be withheld from all inquirers, including family members, spouse/partner, friends, medical providers, or law enforcement personnel except in cases of life-threatening situations, child abuse, or with the written request of the client.
  • The right to receive services whether or not a member is currently receiving medical care for HIV/AIDS. 
  • The right not refuse or discontinue services at any time for any reason.  This includes the right to inspect all client-specific documents, including intake forms, assessment forms, case notes, and other other documents pertaining to the client only.
  • The right to information pertaining to the grievance and appeals process in the event that a member has a dispute with a staff person or service provider of The Aliveness Project.
  • The right to be protected from sexual, verbal, and/or physical harassment from staff or other service providers.
  • The right to be protected from discharge from membership without due cause, notice and/or process.
  • The right to receive interpretation/translation services (for client with limited English proficiency or hearing impairment), if not staff speaks the client's language or the client has not arranged for an interpreter.\
Non-discrimination Policy

It is the policy of The Aliveness Project that services will be provided to all individuals without discrimination on the basis of HIV status, race, ethnicity, religion, age, sex, gender, sexual orientation, religion, national origin, physical or mental disability, or any basis prohibited by law.

Grievance Policy

You have the right to file a grievance if you feel you have been treated unfairly in any way.  You will suffer no repercussion in service delivery solely as a result of filing a grievance.  All grievances will be addressed in a confidential manner.  If you have a grievance, you should first discuss it with the staff person with whom you are working.  If this is not successful or if you feel that this is not an option, you should proceed with the following steps:
  1. A written statement may be prepared (including date and time of incident) of the grievance.  If you prefer, a grievance may be communicated verbally.
  2. Submit the grievance to the staff person's supervisor.  An appointment will be scheduled for you to meet with the supervisor to resolve your grievance.  If the matter cannot be mediated, your grievance may be referred to the Executive Director for final resolution.
  3. Grievances will receive prompt attention.  Every effort will be made to address and resolve grievances within ten (10) business days.  Written correspondences can be mailed or delivered to 3808 Nicollet Avenue, Minneapolis, MN 55409. 
Member Guidelines
The staff and volunteers of The Aliveness Project would like to welcome you and to insure your safety as well as enjoyment while attending programs and services, we have established several guidelines.  The purpose of these guidelines are required and expected of all members and volunteers.
  1. The consumption of, distribution of, or being disruptive under the influence of alcohol or illegal substances while accessing services at The Aliveness Project, on building property, or at off-site activities is prohibited.
  2. Verbal abuse, sexual harassment, or physical threats directed towards staff, volunteers, or other members under any circumstances are not permitted.  Racial or discriminatory slurs or insults are not allowed.
  3. Viewing sexual explicit material on The Aliveness Project computers or in the building, including pornographic websites or movies with sexually explicit, is prohibited and will result in suspension from computer use.
  4. No guns or any type of weapons are permitted on the premises.
  5. Smoking is not permitted anywhere within our building.  E-cigarettes are included.
  6. According to health code standards, only staff and authorized volunteers are permitted in the kitchen areas.  Shoes and clothing must be worn throughout the building.  
  7. The removal of any items belonging to The Aliveness Project without explicit permission from staff is prohibited.
  8. No animals of any kind are permitted in the dining room, with the exception of service animals.  Reasonable accommodation can be discussed with Member Services.
  9. Misrepresenting oneself as a member, volunteer, or staff of The Aliveness Project is prohibited.
  10. Personal items may not be left or stored at The Aliveness Project.  Unclaimed items will be placed on the "free table" after three days.
  11. Program services are limited to use by members only.
  12. It is not the sole responsibility of staff or volunteers to maintain cleanliness of the center.  It is expected that members will clean up after themselves after meals and other activities.
  13. Sleeping is only permitted in lobby chairs and is not permitted at computers or in the dining room.  No food consumption is allowed in the lobby.
  14. When accessing services, members are expected to comply with all program rules that may apply.
  15. Breaching confidentiality by revealing the HIV status of a member or person seen at The Aliveness Project is prohibited.
  16. Members are expected to keep appointments and arrive on time.  We understand that emergencies sometimes occur.  If a member fails to give adequate notice regarding missed appointments, they may face suspension from those specific services.  
  17. Members who sign up for events are expected to attend or give more than 24-hour notice that they will not be able to attend.  Failure to give notice may result in suspension from ticketed events. 
Membership and access to services at The Aliveness Project are a privilege.  We expect members, staff, and volunteers, to behave in an appropriate manner while in our building.  Members who violate these guidelines are subject to having their membership suspended.  Any Aliveness Project employees who violate these guidelines may be subject to suspension without pay or immediate dismissal.  The Aliveness Project's staff and Board of Directors reserve the right to amend these guidelines when necessary.  Members have the right to expect that the changes will be posted within the building. 

Removal of Membership: Suspensions of more than thirty days are deemed grounds for removal. Removal requires a two-thirds vote of the current Membership Advisory Committee (MAC). After removal, a person may reapply for membership after one year. A two-thirds vote from the MAC will be required to regain membership.
Confirmation of Application & Policy Adherence
By providing my e-signature below,  I confirm that I am applying for membership at The Aliveness Project and am eligible to become a member. I have read and understood the membership requirements, policies, and guidelines and agree to abide by the guidelines once I become a member. I have completed the application to the best of my abilities and will reach out if I need more information.