PROGRAMS


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BBL Leader Application
Brown Bag Lunch Leader Application
  1. First Name*
    Please enter your full name
  2. Last Name*
    Please enter your full name
  3. Cell Phone*
    Please enter your phone number in XXX-XXX-XXXX format
  4. Work Phone*
    Please enter your phone number in XXX-XXX-XXXX format
  5. Personal Email*
    Please enter a valid email
  6. How are you primarily connected to HIV/AIDS work? (Select one.)*
    Invalid Input
  7. Name of Employer/Academic Institution
    Invalid Input
  8. Job Title*
    Please enter a valid city
  9. Professional Email*
    Please enter a valid email
  10. Work Phone*
    Please enter your phone number in XXX-XXX-XXXX format
  11. Work Address*
    Please enter a valid address
  12. City
    Please enter a valid city
  13. State*
    Please enter a valid state
  14. Zip*
    Please enter a valid zip code
  15. If you are involved with any community based-organizations or programs that do HIV/AIDS work please list the group’s information below.
  16. Organization Name
    Invalid Input
  17. Street Address*
    Please enter a valid address
  18. City
    Please enter a valid city
  19. State
    Please enter a valid state
  20. Zip
    Please enter a valid zip code
  21. Phone
    Please enter your phone number in XXX-XXX-XXXX format
  22. Fax
    Please enter your phone number in XXX-XXX-XXXX format
  23. Website
    Please enter a valid email
  24. Populations served (check all that apply):*
    Invalid Input
  25. Do you work consistently (engaging at least once per month) in organizations that are in the following fields? (check all that apply):*









    Invalid Input
  26. I will attend the Leader Orientation Webinar on:*
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  27. By submitting the application to be a Brown Bag Lunch Leader below, I attest that all information and statements in this application are true, complete and honestly prepared to the best of my knowledge. I further understand and acknowledge that if selected, I am making a commitment to contribute time, skills, and resources to the program. Additionally, I agree to follow all policies and procedures, including:

    • Attending one Leader Orientation webinar.
    • Completing all preparation and follow-up work related to the Train-the-Trainer webinars and the Brown Bag Lunches.
    • Attending a minimum of four Train-the-Trainer webinars.
    • Securing a venue for the Brown Bag Lunch Events.
    • Implementing four Brown Bag Lunch events on standard dates.
    • Completing evaluations for all Train-the-Trainer webinars attended.
    • Circulating and collecting evaluations at all Brown Bag Lunch events implemented.

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