Building Leaders of Color (BLOC) 2018 Application

I am applying to attend the *

First Name *

Last Name *

HIV Organization Affiliation, if any:

Address 1 *

City *

State *

Zip *

Phone *

Phone Type

Can we send you text messages? *

Alternative Phone

Email *

Work or personal email

How do you own any electronics? (Check all that apply) *

Computer
Tablet
Cell phone
None

How would you describe your computer skill level? *

Beginner
Intermediate
Advanced

Gender Identity: *

Ethnicity: *

Age Range *

What is your current age? *

In what year were you diagnosed with HIV?

What is your current employment status?

Unemployed
Self-employted
Full time
Part time
Student

If you’re currently employed, how long have you been with your organization?

less than a year
1-3 years
3-6 years
6+ years

Will your employer support you attending participation the training?

Yes
No
Unsure

Do your employer receive Ryan White Part A or B funding? (check all that apply)

Part A
Part B
Part C
Part D

What 3 priority issues affecting people living with HIV (PLWH) concern you the most? *

Have you ever worked or volunteered in an aids service organization? *

Yes, currently
Yes, previously
No

If so, what was your title/ duties?

Have you served on an HIV planning council or advisory board? If so, which one?

If so, when and for how long?

How were you prepared to serve board or committee?

Did you serve in leadership role i.e. chair, treasurer, or etc.?

Have you led a support group? *

Yes, for 1 year or less
Yes, for more than 1 year
No

Have you ever led a workshop? *

Yes, more than 5 times
Yes, 3 or 4 times
Yes, 1 or 2 times
No

Have you attended other leadership trainings? If so, please list which one(s) you found personally or professionally useful. *

What pieces or topics of the training did you find most useful?

On a scale one to ten, how would you rate your level of public disclosure? (1 = no-one knows but my clinic team, 5 = I have shared with friends or family, 10 = I have done interviews in magazines or TV).

Which social media do you interact with the most?

Do you understand upon completion of the in-person training, we expect participants to identify local planning and advisory opportunities to join and be an active participant for up to one year. If selected for this training, are you committed to this level of participation? *

Yes
No
Unsure

Tell us why you want to be part of this program? *

Share your leadership experiences as a person of color living with HIV.

(Youth BLOC Only) I understand I will have a roommate for all person trainings *

I agree
I do not agree
Over 24 (N/A)

If you disagree to having a roommate please explain any special needs that will prevent you from being paired with another youth. We will consider your request, but we can not guarantee you will get a single room.

Is there anything else you’d like us to know? i.e. special accommodations, limited vision, limited mobility, special skills, diet restrictions, or interest

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Building Leaders of Color (BLOC) 2018 Application