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)

Yes

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City Province Postal Code

Anything sent through Canada Post will be sent in a plain envelope – NO HIV/AIDS designation or logo will be used.

Phone - daytime(Required)

Phone - evening

If we get voice mail or answering service, may we leave a message?(Required)

Yes

Email(Required)

PAN member agency endorsing your application(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]

Name of Executive Director or support staff endorsing application.(Required)

Indicate the training dates you are applying for(Required)

November 12-15, 2020

How did you hear about this training?(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)

19-29

30-40

41-51

51+

2. Education: Highest Level Completed(Required)

Some high school (please use "Additional Information" space below to indicate grade level)

High school diploma

College

University

University - post graduate

Education- Additional Information

3. Ethnicity(Required)

Indigenous / First Nations

Asian

South Asian

Middle Eastern

Hispanic/Latinx

Black/African/Caribbean

White/Caucasian

Multi-racial

Other (please list)

Ethnicity- Other

4. Gender Identity(Required)

Gender Identity not covered above

5. Sexual Orientation(Required)

Straight

Lesbian

Gay

Two-Spirit

Bisexual

Queer

Pansexual

Asexual

Other (please specify below)

Sexual Orientation not covered above

6. Do you identify as a newcomer or new immigrant to Canada?(Required)

Yes

7. English Language Comprehension(Required)

Fluent – first language

Fluent – second language

Basic conversation only

Need assistance

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)

Yes

1 b). Do you require childcare subsidy/reimbursement?(Required)

Yes

2. Do you have any special physical needs that might affect your participation in the training such as: visual or hearing impairment; use a wheelchair or experience mobility challenges; etc.?(Required)

3. Allergies or food restrictions? Please state below:

4. Have you previously applied for Core Leadership Training?(Required)

Yes

5. Were you accepted to a Core Leadership Training in the past but could not attend?(Required)

Yes

If you were accepted to Core Leadership Training in the past but couldn't attend, please tell us why.

6. Please list and describe your involvement with the HIV/AIDS community and/or other community involvement and leadership activities:(Required)

7. What skills would you like to develop in order to be more effective in your community work? What are your leadership goals?(Required)

8. How would you describe a good leader; what specific qualities does this person have to make them a good leader?(Required)

9. Please describe how you plan to use the learning from this training in your community work: how will the training help you achieve your leadership goals?(Required)

10. Please describe how you plan to share your experiences at the training with other PLHIV in your community:

11. Please tell us a little about yourself. Why should you be accepted to this training?

Emergency Contact Information

The following information is required in case of an emergency:

Your Name(Required)

First Last

Emergency Contact(Required)

First Last

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]

Phone Daytime(Required)

Phone Evening(Required)

Relationship:(Required)

Does this person know your HIV status?(Required)

Yes

Medical conditions(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)

First Last