2021 Leadership Application Form

Selected nominees will be notified on March 26, 2021.

Purpose: The 2021 National Latinx Leadership Institute will create a space for emerging Latinx leaders to enhance their skills and abilities to effectively lead.

Work Plan: The institute will be led by experts that will focus on leadership in HIV Medical Care, Social Services & Mental Health, HIV Prevention & Advocacy, and Program Management. These targeted fields align with the current National HIV/AIDS Strategy from prevention work to viral suppression.

The institute will be an 6-hour pre-work, virtual coaching, and training session.

Agenda coming soon!

The Coach and participants will set goals and expectations for the entire proposed program. After the virtual training at the leadership institute, the Coach will set up two 1-hour video calls to follow up with their respective groups. These calls will start off with a 15 minute didactic on leadership techniques, then followed up by an update on individual goals and feedback.

The participants who apply to be part of a specific field will expect the following:

HIV Medical Treatment: The participant profile: Candidates for the leadership institute will be medical school residents, licensed Nurse Practitioners, Physician’s Assistants, Medical Doctors, and Doctors of Osteopathy. Candidate does not have to currently be in a management or supervisory positon to apply.

Participant goals should focus on developing programs in their clinics that address treatment as prevention, HIV medical care, increasing treatment adherence. These programs can include but not limited to developing protocols, referral processes, and or staff coaching.

Mental Health & Social Services: The participant’s profile: Candidates for the leadership institute will be Mental Health providers, LCDC’s, Social Workers, Medical Case Managers and other type of care management providers. Candidate does not have to currently be in a management or supervisory positon to apply.

Participant goals should focus on developing or adapting innovative strategies to address the social needs of the patient in order to achieve access, retention and viral suppression. The participant in return will be able to coach their peers or team they manage to achieve the success of program implementation.

HIV Prevention and Advocacy: The participant’s profile: Candidates for the leadership institute will be outreach workers, community health workers, community organizers and other health educators. Candidate does not have to currently be in a management or supervisory positon to apply.

Participant Goals should focus on developing or adapting innovative strategies to address the increasing rates of HIV in the Latinx community, creating campaigns that are culturally appropriate, and or organizing the community events that have an impact on HIV prevention, access to care, and retention to care.

Program Management: The participant’s profile: Candidates for the leadership institute will be administrators such as CEO’s, COO’s, program managers/coordinators, or other community leaders that are vested in the National HIV/AIDS Strategy. Candidate does not have to currently be in a management or supervisory positon to apply. Candidates who are new to their supervisory positions are encouraged to apply.

Participant’s goals should focus on building stronger working teams in their programs, learning and adapting leadership techniques that will achieve success for their program and promote growth for their employees. Participant is to learn new coaching skills that they will be able to teach back to their colleagues which in return should benefit their organization or institute.

Read and Understand the aforementioned Institute description. *

Yes, I have

Select a Leadership Institute field:

HIV Medical Treatment Mental Health & Social Services HIV Prevention and Advocacy Program Management

Full Name *

First Name Last Name

Birthdate: *

Month Day Year

Mobile No. : *

Area Code Phone Number

E-mail : *

Where the confirmation will be send to

Agency that you are representing, if not applicable, enter your home address:

Agency Name or N/A

Street Address Line 1

City State / Province

Postal / Zip Code Country

If representing an agency, what is your title?

Gender:

Male Female Transman / Transgender Male Transwoman / Transgender Female Non-binary / Third Gender

What sex were you assigned at birth?

Male Female Decline to state

Race:

White Black or African American Asian American Indian or Alaskan Native, Hawaiian, or Other Pacific Islander

Ethnic Origin:

Hispanic Non-Hispanic

If Hispanic, please select your Ethnic Subgroup:

What is your sexual orientation

Straight/Heterosexual Gay or Lesbian Bisexual Prefer not to say

What is your highest level of education?

High School 2 years of college BA/BS Master PhD MD

How many months/years of HIV Work Experience do you have?

How long have you been in a Supervisor/Management role?

What would you like to learn from the Leadership Institute?

What have been your greatest leadership/professional challenges throughout your career? How do you feel this training will help you overcome them?

Describe what you think other program participants may learn from you (perspectives, skills, expertise).

Provide a 500 or less word Bio

Please attach a Headshot/Photo (Not required. Photo and Bio will be used in promotional materials for the Leadership Institute)

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By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received.

E-Signature: *

Latinx Leadership Application Form

I. Personal Data:

VII. Open Ended Questions

VIII. Applicant's E-Signature