WORLD Leadership Institute Application

WORLD Leadership Institute Application
Are you applying for *

Spring session Fall session
Full Name *

First Name Middle Name Last Name
Present Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Mobile Number *
Email Address *
Permanent/Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Gender *

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 *

Black/African American Asian/Pacific Islander Latina/Latinx Native American White
Age Range *

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.) *

Yes No It depends/I am not sure yet
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? *
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: *

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
Experience
What experience do you have working in the HIV/STI field/ community: *
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. Cancel 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. *
Signature of Applicant

First Name Last Name
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WORLD Leadership Institute Application

OPTIONAL - Comorbidities

Areas of Interest

Experience

References:

Statement of Purpose