2020 HIV Leadership Academy Application Question Title * 1. Full Name (please print): Question Title * 2. Title (if applicable): Question Title * 3. Contact Mailing Address: Question Title * 4. City Question Title * 5. State: Question Title * 6. Zip Code: Question Title * 7. Applicant Contact Phone: Question Title * 8. Applicant Secondary Phone: Question Title * 9. Applicant Contact E-Mail: Question Title * 10. Supervisor Contact E-Mail: Question Title * 11. What is your gender? Male Female Transgender (Male to Female) Transgender (Female to Male) Non-Binary Non-Conforming Question Title * 12. What is your race? White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander Mixed/More Than One Race Other (please specify) Question Title * 13. What is your ethnicity? Hispanic or Latinx Not Hispanic or Latinx Other (please specify) Question Title * 14. Are you able to devote six hours (6) per month for the next three (3) months to the HIV Leadership Academy by attending two (2) monthly training sessions (March-May 2020)? Yes No Question Title * 15. Can you obtain written permission from your work supervisor to attend all sessions? Yes No Question Title * 16. Please explain why you are interested in attending the HIV Leadership Academy (100 words or less) Question Title * 17. What would you like to gain from participating in the trainings of the HIV Leadership Academy? (100 words or less) Question Title * 18. What is your current level of involvement in the area of HIV prevention, care and treatment? (100 words or less) Done