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 info@engagingarkansas.org.
Contact Info
Please provide your contact information and the best way to reach you.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Way to Be Contacted:
*
Stigma
Please answer these questions about your personal experiences with HIV stigma.
I have encountered HIV stigma with my:
*
Rows
Never
Sometimes
Often
Medical Provider
HIV Case Worker
Family
Friends
Church
Choose how much you agree with the following statements:
*
Rows
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
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?
*
Demographics
Age
*
18-26
27-34
35-44
45-54
55 and older
Gender Identity
*
Cisgender man
Cisgender woman
Transgender man (FTM)
Transgender woman (MTF)
Non-binary
Not listed
Sexual Identity
*
Straight/Heterosexual
Gay
Lesbian
Bisexual
Queer
Questioning
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
Asian
Native Hawaiian/Pacific Islander
Other Race
Submit Survey
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