WORLD Leadership Institute Application
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Spring session
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eSwatini
Sweden
Switzerland
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Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Mobile Number
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Email Address
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Permanent/Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Gender
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Cis female a woman who was assigned female at birth)
Transgender female (a woman who was not assigned female at birth)
Gender non-conforming (someone who doesn’t identify with anassigned gender)
Race
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Black/African American
Asian/Pacific Islander
Latina/Latinx
Native American
White
Other
Age Range
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13-19
20-29
30-39
40-49
50-59
60+
Employer (If Applicable)
Are you comfortable disclosing your HIV+ status to others outside of the Leadership Institute? (Please note that disclosure of HIV status is encouraged, but certainly not required for membership.)
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Yes
No
It depends/I am not sure yet
Other
Please describe any additional support and/or services that would help you be successful in the Institute:
OPTIONAL - Comorbidities
I am a person living with Hepatitis B:
Yes
No
I am a person living with Hepatitis C:
Yes
No
I am a person living with a current or previous diagnosis of an STI/STD:
Yes
No
If you would like to disclose any STIs or other medical conditions, please use this space:
Areas of Interest
What makes you want to be a part of the WORLD Leadership Institute?
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Use this space to identify any councils, boards or advocacy groups that you are currently a member of, any leadership trainings that you have participated in, as well as any special skills/ expertise/ education that you feel as though you will bring to the WORLD Leadership Institute.
*
Please mark all areas of interest, expertise, and/or where you'd like more information:
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Advocacy/Increasing awareness
Community organizing
Health planning
Evaluation of HIV or health services
Public health administration
Provider perspectives
Dental services and needs
Homelessness/Housing services and needs
Substance use/abuse services and needs
Mental health services and needs
PLWHA nutritional services and needs
PLWHA legal and financial services and needs
Primary medical care: Ambulatory/Outpatient
Primary medical care: Antiretroviral therapies
MSM (men who have sex with men) HIV issues and needs
Women's HIV issues and needs
Children/Youth HIV issues and needs
Transgender HIV issues and needs
Incarcerated people living with HIV issues and needs
Formerly incarcerated people living with HIV issues and needs
Immigrant/Migrant HIV issues and needs
Other
Experience
What experience do you have working in the HIV/STI field/ community:
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References:
Please provide one letter of reference that attests to your character and work performance, as well as one additional personal or professional reference:
Letter of reference 1:
Browse Files
If you do not have your letters of reference ready at this time, please indicate in the final box in this section when you will be sending them to WORLD.
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of
Name of person providing the 1st letter of reference:
*
Email and/or phone number:
*
Relationship to you:
*
Best time of day to contact:
*
Letter of reference 2:
Browse Files
If you do not have your letters of reference ready at this time, please indicate in the final box in this section when you will be sending them to WORLD.
Cancel
of
Name of person providing the 2nd letter of reference:
*
Email and/or phone number:
*
Relationship to you:
*
Best time of day to contact:
*
If you do not have your letters of reference ready at this time, please indicate below approximately when you will be sending them to: WORLD, C/O Dr. Demisha Burns, 389 30th St. Oakland, CA 94609 or dburns@womenhiv.org
Statement of Purpose
This section must be completed.
What do you look to get out of the WORLD Leadership Institute and what are your next planned steps upon graduation? Examples include (but are not limited to) applying to sit on a board, start a program, start a support group, do consulting, increase involvement in politics, etc.
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Signature of Applicant
First Name
Last Name
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