/ TUCSON PIMACOLLABORATIONTOENDHOMELESSNESS(TPCH)
ANNUALMEMBERSHIPFORM

MissionStatement

TucsonPimaCollaborationtoEndHomelessness(TPCH)isa coalitionofcommunityand faith-basedorganizations,governmententities,businesses,and individualscommittedtothemissionofendinghomelessnessandaddressingtheissuesrelatedto homelessnessinourcommunity.

GeneralMembership

Any person who attends meetings of the TPCH General Council or one of its Standing Committees is considered a general member. General Members may participate in discussions, projects and other activities.

VotingMembership

To becomeavotingmemberanindividualoranorganizationmust:

  • Complete and submit a membership registration form to the Board Secretary-Treasurer; and
  • Attend three (3) meetings of any combination of the following: General Council meetings, Standing Committee meetings or Subcommittee meetings within a three month period.

MembershipForminformationgatheredwillbe used forTPCHinventoryofprograms,datacollection,analysisof needs/gaps,andcontactinformation.

Pleaseprovidethefollowingforyouragencybasedoncurrentinformation.

Please submit ONE form per agencyto BOTH TPCH Secretary/Treasurer and CoC Administrator at:

and

A / Name
Organization, Agency, or Individual
B / Membership Type
(Check one) / Private Sector
Non-profit
501(c)3
Business
Faith-Based Organization
FunderOrganization
FunderAdvocacy
Hospitals/Med Representatives
Other: / Public Sector
LawEnforcement/Corrections
LocalGovernmentAgencies
LocalWorkforceActBoards
Public HousingAgencies
SchoolSystems/Universities
State GovernmentAgencies
Other: / Individual
Non-Affiliated
C / Populations Served
(Check all that apply) / Chronic Homeless
SeriouslyMentally Ill
Substance Abuse
Veterans
HIV/AIDS / Domestic Violence
Ex-offenders
Individuals Only
Families Only
Both Families & Individuals / Youth (18-24)
Children (>18)
N/A
Other:
D / Services / Do you offer Housing/Shelter Services? YES NO
If YES, How many housing/shelter programs do you operate?
E / Homeless Services Your Agency Provides
(Check all that apply)
*Use these abbreviationsto identify the type of housing/shelter each program providesin section Fbelow. / Homeless Service / Abbrev / Definition
Permanent Housing
Site-based
Scattered Site / PH / Any form of affordable and safe housing that is not a HUD funded Supportive Housing Program or Shelter Plus Care subsidized housing option.
Permanent Supportive
Site-based
Scattered Site / PSH / Housing that includes related supportive services such as for people moving from homelessness to independent, supportive living.
Transitional Housing
Site-based
Scattered Site / TH / Any type of housing where individuals can stay for up to 24 months and receive supportive services such as childcare, job training and home furnishings.
Rapid Re-Housing
Site-based
Scattered Site / RRH / Provides financial homeless prevention assistance and services and helps those who are experiencing homelessness to be quickly re-housed and stabilized.
Emergency Solutions Grant Project(s)
Site-based
Scattered Site / ESG / Assistance to homeless and at-risk families and individuals to prevent eviction, foreclosure, or utility shutoff.
Homeless Outreach Services / HOS / Outreach services to homeless individuals and families.
Emergency Shelter
Mass Shelter
Scattered Site
Motel Vouchers / ES / Temporary shelter provided to homeless individuals and families.
(Please check all applicable types of Emergency Shelter)
Support Services Only / SSO / Projects that address the service needs of homeless persons. Support Services Only project sponsors do not provide housing to the persons receiving their services. Services may be provided in a structure or operated independent of a structure, such as street outreach or mobile vans for health care.
Other:
N/A
F / List All Housing/ Shelter Programs Offered by Your Agency / Program Name / Type * / Name of Program Contact/Manager / Phone # & Email
G / Membership / Which TPCH Committee(s) are you interested in or are currently participating in?
Continuum of Services (CoS)
Coordinated Entry (CE, includes 25 Cities/Zero 2016)
Governance & Planning (G&P)
Homeless Management Information System (HMIS)Communications/Membership
Performance Evaluation & Monitoring (PEM) / Which TPCH Subcommittee(s), Workgroups or special interest areas are you interested in or are currently participating in?
CoS Emergency Solutions Subcommittee
CoS Homeless Youth Subcommittee
CoS Discharge Planning Workgroup
CE Outreach Coordination & Case Conferencing
G&P Conference/Fundraising Workgroup
G&P Membership
G&P Communications/Social Media
HMIS Data SharingWorkgroup
HMIS Street Count Workgroup
Do other individuals from your agency participate in TPCH? YES NO DON’T KNOW
Please explain:
What do you think would assist TPCH in improving membership?
Please explain:
H / Your Contact Info / Your Name
Title
Email
Phone
Date
Your Exec. Director’s Name
Email
Phone
For TPCH Use Only
Received by Name
TPCH Title/Committee
Date

TPCH MEMBERSHIP FORM - Fillable - Rev 2016 03Page 1 of 3