NMAC


Building Leaders of Color Bootcamp Leadership Training
First Name *
Last Name *
HIV Organization Affiliation, if any: *
Address 1 *
City *
State/Province *
Zip *
Phone *
Phone Type *
Can we send you text messages? *
Phone2 *
Email *
Email Type *
Do you have access to a laptop or 10" tablet? *
How would you describe your computer skill level? *
Gender Identity: *
Ethnicity: *
Ethnicity: (other) *
Age *
In what year, were you diagnosed with HIV? *
What is your current employment status? *
If you're currently employed, how long have you been with your organization?
If employed, does your employer receive Ryan White funding ? *
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 ? *
If so, what were your titles/duties?
Have you served on an HIV planning council or advisory board? If so, which one? *
If so, when and for how long?
How did you prepare to serve on a board or committee?
Did you serve in leadership role? i.e. chair, treasurer, or other.
Have you ever led a support group? *
Have you ever led a workshop? *
Have you attended other leadership trainings? If so, please list which ones you found personally or professionally useful.
What parts or topics of the training did you find most useful?
On a scale one to ten, how would you rate your level of public HIV disclosure? 1 = no-one knows but my clinic team, 5 = I have shared with friends or family, 10 = I have done *
Which social media do you interact with the most? *
Tell us why you want to be part of this program. *
Share your leadership experiences as a person of color living with HIV, if any. *
Is there anything else you would like us to know about you? i.e. special accommodations, limited vision, limited mobility, special skills or interest

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Building Leaders of Color Bootcamp Leadership Training