Application Form PLDI – Core Leadership October 2017

 

 

 

 

 

Training dates: Oct 19 – 22, 2017

Training Location: Silver Star Resort, Vernon BC.

 

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 Positive Leadership Development Institute – Core Leadership Training. By signing 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 Jaydee Cossar [email protected]

 

Contact Information
Please provide a valid mailing address and email to ensure safe and confidential delivery of materials. All surface mailings will be sent in a plain envelope – NO HIV/AIDS designation or logo will be used. Please note: Incomplete applications will not be reviewed, please ensure that you have fully completed the application.

 

 

2017- October- PAN/OAN PLDI Core Leadership

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

Your Profile

Please answer ALL of the following questions to help us support your involvement in the training:
1. Do you require refrigeration for medications?(Required)
2. Do you require childcare subsidy/reimbursement?(Required)
4. Have you previously applied for the PLDI Core Training?(Required)
4. Were you accepted to a previous Core training but were unable to attend?(Required)
5. Have you had previous experience in a large group setting?(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 Jaydee Cossar
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 Positive Leadership Development Institute – Interior Core Leadership Training.
Name(Required)
Date(Required)