"Be The Change! Southern Sustainability Capacity Building Institute

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Registration Form
Institute Title: Be The Change Institute: Implementing Core Strategies for Sustainable Organizations for Impact in the South

Register today for the Southern Sustainability Capacity Building Institute for HIV Prevention Service Providers. This event is a two-and-a-half day collaboration event of ETR's Community Impact Solutions Project (CISP) and PROCEED, Inc. National Center for Training, Support, and Technical Assistance.

DatesMay 2-4, 2017
Location: Omni Riverfront Hotel, 701 Center Boulevard, New  Orleans, LA 70130    

Institute Tracks                          
Track AOrganizational Sustainability - For Executive Directors, Program Directors and Program Coordinators
Track B: Program Mastery - For direct service provider staff including, HIV Testers, Community Outreach Specialists, Patient Navigators, Linkage to Care Coordinators


Participation in the Institute Tracks will be determined by the individual's position and role within the organization, "i.e. Executive Directors select Track A, HIV Testers select Track B."
*In order to make this training most effective, we recommend registering two people from your organization - one person for Track A and one person for Track B.
Please complete all questions in the registration form below. This will help to guide us in completing your registration for the Institute. Your registration includes completing the Health Professional Application for Training (HPAT) survey.
1. Demographics *This question is required.
2. Are you attending the institute with another member from your agency? 
3. What is the name and title of the colleague who is attending the institute with you?
3. Please select the appropriate institute track that coincides with your role within your organization. *This question is required.
4. What are the major funding sources for your HIV Prevention programs?  (Select all that apply) *This question is required.
5. What populations are the focus of your HIV Prevention, Care or Treatment program? (Select all that apply) *This question is required.
6. How many years have you been working in the field of HIV Prevention, care or treatment? *This question is required.
7. A limited number of Scholarships to the Institute might be available. Would you be interested in applying? *This question is required.
8. Please indicate your own commitment to support internal capacity around one or more of the following topics.
Closing Statement with Health Professionals Application for Training (HPAT) 

The next section of the form contains HPAT information. Once you have completed the HPAT section, hit submit and you will be sent an e-mail confirming your attendance to the institute.

If you have any questions or need additional information, please contact Jacqueline Peters.

Funding for this Institute was made possible by the Centers for Disease Control and Prevention via Cooperative Agreement Numbers U65PS004459 and U65PS004430 under Program Announcement PS14-1403 – Category B- CBA for Community- Based Organizations."