Building Leaders of Color (BLOC) 2018 Application
I am applying to attend the *
Trans BLOC Meeting(Persons of Trans-Experience only).
Regional BLOC Training (all persons of color)
YouthBLOC (ages- 18-24only)
First Name *
Last Name *
HIV Organization Affiliation, if any:
Address 1 *
City *
State *
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
AMERICAN SAMOA
FEDERATED STATES OF MICRONESIA
GUAM
MARSHALL ISLANDS
NORTHERN MARIANA ISLANDS
PALAU
PUERTO RICO
U.S. MINOR OUTLYING ISLANDS
VIRGIN ISLANDS
ARMED FORCES AMERICAS
ARMED FORCES
ARMED FORCES PACIFIC
ALBERTA
BRITISH COLUMBIA
MANITOBA
NEW BRUNSWICK
NEWFOUNDLAND AND LABRADOR
NOVA SCOTIA
NORTHWEST TERR.
NUNAVUT
ONTARIO
PRINCE EDWARD ISLAND
QUEBEC
SASKATCHEWAN
YUKON
Zip *
Phone *
Phone Type
Home
Business
Mobile
Can we send you text messages? *
Option 1
Option 2
Option 3
Alternative Phone
Option 1
Option 2
Option 3
Email *
Work or personal email
Work
Personal
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: *
Female Male Intersex FTM or Trans Man MFT or Trans Woman Gender Queer Gender Non-Conforming Androgynous Cross Dresser Two Spirit Other Prefer Not to Disclose
Ethnicity: *
African American/Black Asian American Indian/Alaska Native Caucasian/ White Latina or Hispanic Non Hispanic Native Hawaiian/ Pacific Islander Native Hawaiian or Pacific Islander Asian/Pacific Islander Other
Age Range *
18-24
25-34
35-44
45-54
55-64
65+
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).
1
2
3
4
5
6
7
8
9
10
Which social media do you interact with the most?
Facebook
Instagram
Twitter
Tumblr
Other
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