Black Treatment Advocates Network

2013 National Network Membership Application

BTAN National Network Application Acknowledgement

By applying for the National Network of the Black Treatment Advocates Network and signing 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 set forth by the National Network of the Black Treatment Advocates Network.

Prospective Advocate’s Signature Printed Name Date

(Electronic Signature Is Accepted)

SECTION I

First Name: Last Name:

Cell Phone: Home Phone:

Personal Email: Fax:

Home Address:

City: State: Zip:

How are you primarily connected to HIV/AIDS work? (Select one.)

I work for an AIDS service organization, or have a job in the HIV field.

Though my job is not in the AIDS field, I am involved in community organizing efforts that address HIV.

I have a personal interest in HIV activism.

I am, or someone I know is, infected with or affected by HIV/AIDS.

Name of Employer/Academic Institution: Job Title:

Professional Email: Work Phone:

Work Address:

City: State: Zip:

If you are involved with any community based-organizations or programs that do HIV/AIDS work with African American populations, please list the group’s information below.

Organization name:

Street address:

City:State: Zip:

Phone: Fax:

Website:

SECTION TWO

Do you work consistently (engaging at least once per month) in organizations that are in the following fields? (check all that apply):

Public Health

AIDS Service Work

Clinical Organizations

Faith Based Organizations

Educational Organizations

Community Based Organization

Traditional Black Institutions (ex. NCNW, NAACP, National Pan-Hellenic Council, etc)

Media/Art/Entertainment Organizations

Political/Advocacy Organizations

Of the types of organizations you selected, specify which groups you are associated with and describe that involvement.

In what city and state do you intend to implement most of your National Network initiatives?

Please list all local, regional, or national coalitions you are a member of, if any:

What types of community mobilization activities have you been a part of in the past two years, if any?

How will you use the information learned from the National Network of BTAN to increase access to and use of HIV prevention, testing, and treatment services in your community?

SECTION THREE

Date of birth (MM/DD/YYYY): / /

Gender:

Female

Male

Transgender, Male to Female

Transgender, Female to Male

Other

Decline to state

Race/ethnicity (check all that apply)

African American/Black

Caucasian/White

Latino/Hispanic

Asian

Pacific Islander

Native American

Other (Please specify )

Decline to state

If you selected African American/Black as your race, what is you ethnic background? (check all that apply)

African American from the United States

Continental African (Specify the country and/or tribe)

Caribbean (Specify the country)

Afro-Latino (Specify the country)

Other (Please specify)

Education

High school diploma or GED certificate

Technical training program

Some college

College degree (A.A. and/or B.A.)

Graduate/professional degree

Certifications (list them)

Other

Sexual orientation

Bisexual

Gay/homosexual/same gender loving

Heterosexual/Straight

Lesbian/ homosexual/same gender loving

Other

Decline to state

HIV-Status

Positive

Negative

Decline to State

SECTION FOUR

As described in the BTAN overview, the National Network is organized into five committees and five working groups. Each Advocate will be expected to engage in one committee and one working group. For a detailed description of the expectations, please review the overview.

Rank your top three committee preferences using 1 to note the committee you wish to be a part of most.

Advocacy and Community Organizing Committee

Communications Committee

Executive Committee (must be elected)

Leadership Development Committee

Policy Committee

Rank your top two working group preferences using 1 to note the committee you wish to be a part of most, and 2 to indicate your secondary interest, if needed. Please note that Working Groups are intended for people who self identify as a part of the respective population, or who work with African Americans from the specified demographic. (For example, persons in the Working Group for Women should be female, or individuals who work directly with Black women.)

Working Group for Heterosexual Men

Working Group for Men who have Sex with Men

Working Group for People Living with HIV/AIDS

Working Group for Women

Working Group for Youth and Young Adults

Prospective Advocate Memorandum of Agreement

This Memorandum of Agreement (MOA) is in recognition of the undersigned’s participation in various training and engagement initiatives through the National Network of the Black Treatment Advocates Network. Should the undersigned be accepted to this program, they will be required to participate in assessment, capacity-building, and mobilization activities that promote access to HIV prevention services, HIV testing, and high-quality medical care.

The National Network of the Black Treatment Advocates Network is dedicated to:

  • Ensuring the training content and curriculum are comprehensive, age-specific, and culturally competent.
  • Ensuring that faculty and staff are experienced in their fields.
  • Supporting the undersigned’s ability to engage in activities that increase HIV science literacy, advocacy for treatment, and ability to re-tool in the changing AIDS field.
  • Supporting the undersigned’s ability to engage in activities that increase community mobilizations around the full implementation of the Affordable Care Act, full expansion of Medicaid, and increasing the demand on HIV treatment.
  • Providing leadership opportunities as they arise.
  • Providing regular contact, support, and guidance throughout the entirety of the program in collaboration with the committee/working group Chairpersons.

The Undersigned agrees to:

  • Participate fully and be on time to all training activities
  • Engage in National Network-related activities associated with Advocate’s work group/committee responsibilities. This includes but is not limited to responding to emails, taking conference calls, following up on tasks, completing homework etc.
  • Engage in two conference calls per month for the Advocate’s committee and working group meetings. Advocates are expected to contribute to the 60- to 90-minute calls by engaging in dialogue, completing related assignments, and helping formulate ideas to implement the plans of the committee.
  • Attend all three national webinar trainings that prepare stakeholders to engage in mass mobilization efforts. Webinars will be between 60-90 minutes and will occur monthly in the second, third, and fourth quarter of the year
  • Develop and implement an action plan of activities based on capacity-building trainings.
  • Participate in essential events and initiatives that involve implementing community mobilization events in the Advocate’s local area.

Signature of Prospective Advocate and Printed Name

(Printed or Electronic Signature Is Accepted)

TO BE COMPLETED BY BTAN STAFF

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Leisha McKinley-Beach, Director of Technical Assistance and Stakeholder Engagement

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Raniyah Copeland, Director of Training & Capacity Building