Application: PLDI Core Training 2020

Positive Leadership Development Institute Core Training events is scheduled to take place at beautiful Loon Lake, on the traditional, ancestral, and unceded territory of the q̓íc̓əy̓ (Katzie) people.

The PLDI Core Leadership Training “Who Am I as a Leader?” for June 18-21, 2020 has been cancelled, a decision made during the evolving COVID-19 outbreak which would have impacted the health and safety of our HIV- positive participants and the peer-led PLDI Training team. We still expect to offer the Core Leadership Training “Who Am I as a Leader in November 12-15, 2020 and are accepting applications.

Questions marked with a * require a response.

 

By completing this application I am aware of, understand and agree to, the Financial Guidelines, the Code of Conduct and the Release of Liability and wish to submit this application to attend the PAN/OAN/COCQ-SIDA Positive Leadership Development Institute Bored? Get on Board Training. By submitting this application, I acknowledge that PAN collects and shares data, excluding names and contact information, with our funders. PAN works to protect your right to privacy, if you have any questions about how this data is used, please contact [email protected] (Marc Seguin)(Required)
Name(Required)
Address(Required)
Anything sent through Canada Post will be sent in a plain envelope – NO HIV/AIDS designation or logo will be used. 
If we get voice mail or answering service, may we leave a message?(Required)
Note: We respect a small minority of people may not have an ongoing relationship with a PAN member agency , if this is the case please contact: Marc Seguin for further discussion. [email protected]
Indicate the training dates you are applying for(Required)

General Information

This information is collected to help ensure diversity of participants in the training and for program reporting purposes (Names will not be associated with the information reported):
1. Age Range(Required)
2. Education: Highest Level Completed(Required)
3. Ethnicity(Required)
5. Sexual Orientation(Required)
6. Do you identify as a newcomer or new immigrant to Canada?(Required)
7. English Language Comprehension(Required)

Your Profile

Please answer ALL of the following questions to help us support your involvement in the training:
1 a). Do you require refrigeration for medications?(Required)
1 b). Do you require childcare subsidy/reimbursement?(Required)
4. Have you previously applied for Core Leadership Training?(Required)
5. Were you accepted to a Core Leadership Training in the past but could not attend?(Required)

Emergency Contact Information

The following information is required in case of an emergency:
Your Name(Required)
Emergency Contact(Required)
Please note: your Emergency Contact cannot be a support person, Executive Director, or Health Care provider. In cases of emergency Pacific AIDS Network must easily be able to reach the person you have listed. Emergency contacts should be reserved for family and close friends. If you have questions please contact Marc Seguin: [email protected]
Does this person know your HIV status?(Required)
Please list any medical conditions or medications we should be aware of

Confirmation

I am aware of, understand and agree to, the Financial Guidelines, the Code of Conduct and the Release of Liability and wish to submit this application to attend the PAN/OAN/COCQ-SIDA Positive Leadership Development Institute Core Leadership Training.
Name(Required)