Interior Health Client Survey Draw

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City Province Postal Code

Telephone Daytime(Required)

Telephone Evening(Required)

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

Yes

Email(Required)

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 (Click to choose from drop-down menu):(Required)

2. Education- Highest Level Completed (Click to choose from drop-down menu):(Required)

Education- Other

3. Ethnicity (Click to choose from drop-down menu):(Required)

Ethnicity- Other

4. Gender (Click to choose from drop-down menu):(Required)

5. Sexual Orientation (Click to choose from drop-down menu):(Required)

6. English Language Comprehension (Click to choose from drop-down menu):(Required)

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)

Yes

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

Yes

3. 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 mobility problems; etc. and/or allergies or food restrictions?(Required)

4. What year (Approx) did you complete Core Leadership Module 1 training?(Required)

5. Have you completed other PLDI Modules?

Yes, Communication Skills Module 2

Yes, Bored? Get on Board! Module 3

No, I have not completed either Module 2 or 3

5. a) if you have not completed Module 2 or 3 please explain your front line or peer work experience that would make you a candidate for this training.

6. Have you had other training designed to support people with mental health challenges?(Required)

Yes (Please describe below)

6. a) Please describe the training if you answered yes above.

7. What are your 3 reasons for wanting to attend the MHFA course in March?(Required)

8. Please list and describe your involvement with the HIV/AIDS community and/or other community involvement as well as leadership activities that would make you a candidate for MHFA Training.(Required)

9. Please provide a specific example of how you have supported an individual with mental health problems.(Required)

Your answer needs to demonstrate that you have some knowledge or lived experience, not mastery, of mental health disorders and supports. We are interested in your experiences and skills that would enable you to participate in this course. There are no wrong or right answers. Focus on your experiences supporting a client, friend, family or community member. Use Jane Doe or John Doe only. Do not use the real names of the people you supported. In your response tell us: What happened? What you did? Why you believe it was successful and/or what you needed to improve.

10. Please describe how you plan to use the learning from this MHFA leadership training in your community work OR everyday life:(Required)

11. Is there anything else you would like us to know?

Application check list(Required)

I have read PAN's Financial Guidelines & Code of Conduct

I understand that MHFA is about learning to support others and not for personal problem solving

I understand I must attend all 12 hours of this course to receive a MHFA Certificate

I want to be wait-listed for this course

Emergency Contact Information

The following information is required in case of an emergency:

Your Name(Required)

First Last

Name of 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 the Pacific AIDS Network must be able to easily reach the person you have listed. Emergency contacts should be reserved for family and close friends. If you have questions please contact Jaydee Cossar

Phone Daytime(Required)

Phone Evening

Relationship:(Required)

Your emergency contact must not be a Support person, Executive director, or Health Care provider

Does this person know your HIV status?(Required)

Yes

Medical conditions(Required)

Other than HIV and food allergies 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 Hosted Positive Leadership Development Institute Mental Health First Aid course.

Name(Required)

First Last

Date(Required)