Peer Leadership Interest Form
We're excited you are interested in the E-P-I-C+ Peer Leadership Program! Please tell us a little about yourself and a member of our team will reach out to you with more information. (There are no right or wrong answers here!) If you have a specific question about the program, please reach out to us at firstname.lastname@example.org.
Please provide your contact information and the best way to reach you.
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Preferred Way to Be Contacted:
Please answer these questions about your personal experiences with HIV stigma.
I have encountered HIV stigma with my:
HIV Case Worker
Choose how much you agree with the following statements:
My uderstanding of BASIC HIV INFORMATION is very strong.
I feel I could explain basic HIV information to another person.
My understanding of HIV TRANSMISSION is very strong.
I feel I could explain HIV transmission to another person.
Why would you like to join this training?
55 and older
Transgender man (FTM)
Transgender woman (MTF)
Terms do not apply
Do you identify as Hispanic/Latino/a, or of Spanish Origin?
Hispanic/Latino/a, or of Spanish Origin
Non-Hispanic/Latino/a, or of Spanish Origin
Race (mark all that apply)
Black or African-American
American Indian or Alaska Native
White or European American
Native Hawaiian/Pacific Islander
Should be Empty: