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POSITIVE:~
MEMBERSHIP APPLICATION
LIVING
SOCIETY
O F' BRITISH COLUMBIA
The Positive Living Society of BC exists to enable persons liv ing w ith AIDS and HIV
disease to empower themselves through mutual support and collective action.
803 East Hastings Stret,
Vancouver, BC, V6A 1R8
t 604.893.2262
1.800.994.2437
e [email protected]
A ll information gathered will be kept private and confidential.
Your membership information is neve r shared w ith any member, organization or
gove rnment agency w ithout your consent. To rev iew Positive Living BC's complete
Privacy Policy, please vi sit www.positive livingbc.org/privacy or ask
Member Services to provide you w ith a printed cortt.
Application Date
Last Name:
First & Middle Name:
Address:
City:
Post al Code:
If applicable can we send mail to the above addre ss?
Indicate here if you have no fixed address:
mai~in
0
0
" Positive Living BC members are mailed Posidve Living magazine
in late Spring, and
YES
b ~m onthly,
an A nnu al General Meeting Package
ballots and Society notices w hen necessary.
A ll mail from Positive Living BC is discreetly posted in unm arked enve lopes.
If you do not want to receive Positive Living magaz.ine, check he re:
O
Send Po sitive Living BC mail to me at this a lternate add ress:
Address:
City:
Home Telephone:
Postal Code:
'---~~~~~~~---'
Alternate Telephone:
Is discretion needed?
YES
Is discretion needed?
0
YES
"Positive Living BC telephones members only when absolutely necessary.
Caller ID displays our office numbe r as "Private Caller" or "restric ted" .
In other instances, may we indentify our call as coming from Positive Living BC? YES O
NO
0
0
NO
0
NO 0
Email address:
"Positive Living BC members are emailed the Positive Living eNews
b~weekly
and Society updates or notices from time to time.
If you do not want to receive Positive living BC email s, c heck here O
After your application is processed, a Positive Living BC Me mbe rs hip Package will be pre pared for you.
Do you want your membership package: Held for pickup 0
POSmVE LWH: llC Membe r shi p Applicati"'
o un _ _ __
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Mailed t o addre ss provided
0
CONl1IDF.Nl'IAL
POSITIYE;9-_
LIVING
SOCIETY
OF BRITISH COLUMBIA
Positive Living BC uses the following information to develop better, more relevant programs and
services for our members. This information is never shared with any member, organization or
government agency without your consent.
Gender:
Male
<>
Sexual Orientation (optional) :
Female <>
0
Transgender: Male to Female <>
Straight
Transgender: Female to Male <>
Bisexual <>
What is the highest level of education you have?
Primary language?
Primary/ Elementary <>
English
High School <>
College/ University<> Post graduate <>
Other:
Other:
0
Gay/ Lesbian
Other :
0
MSM
0
'------------'
French
0
'------------'
'-----------'
Ethnicity
First Nations <> Caucasian <>
Did you originally contract HIV
through any of the following activities?
(please check only one) (optional)
Sex with women <>
Blood transfusion
0
Other:
Metis <>
African <>
South Asian <>
Hispanic <>
'-----------'
Sex with men <>
Occupational exposure
Intravenous d rug use/ share needles <>
Other:
Inuit <>
Asian <>
'--------~
0
How did you hear about Positive Living BC? (choose only one)
Web research <>
AIDS Service Org.
Doctor
<>
0
Hospital/ Clinic
Street Nurse
Positive Living BC event <>
<>
Public Health Nurse
or a language barrier <>
<>
Posi6ve Living Magazine <>
Social networking tool (Facebook, etc.) <>
To help improve our services,
please indicate if you have a disability
(e.g. limited mobility, hearing or visual
impairment, mental health issues, etc.)
0
HIV+ Peer<>
Peer Navigator <>
Primary income source?
Employed <>
Self Employed <>
BC Employment and Assistance for Persons with Disabilities <>
Canada Pension Plan Disability
BC Employment Assistance <>
0
Long Term Disability
Other:
0
'------------'
CONl11DllN'flAf,
POSITIYE.9-_
LIVING
SOCIETY
OF BRITISH COL UMBIA
IABOUT THE POSITIVE LIVING SOCIETY OF BC I
The Positive Living Society of BC exists to enable persons living with AIDS and HIV disease to empower
themselves through mutual support and collective action. We are Western Canada's largest AIDS service
organization with a membership of more than 5,000 HIV+ individuals. Unique among major HIV/AIDS agencies
in Canada, the Positive Living Society of BC's Board of Directors is composed entirely of HIV+ members.
The Positive Living Society of BC provides its members with a wide variety of services to
manage the challenges of living with HIV/ AIDS. Membership is free for HIV+ British
Columbians, and benefits include:
• Complementary Health Fund
• Support Groups
• Counselling
• Drop.in Lounge and Internet Cafe
• Advocacy
• Income tax preparation assistance
• Treatment Information
• Free subscription to Positive Living magazine
• Social and Special Events
• Full voting rights & the opportunity to shape the future of the organization
• Healing Retreats
• Massage therapy, professional hair styling, and much more!
Protecting Your Privacy:
The Society is committed to protecting your personal information and holds all membership
information in the strictest confidence. Your membership information is never shared with any
member, organization, or government agency without your consent.
To view our complete Privacy Policy please visit www.positivelivingbc.org/privacy or ask at the
Positive Living Society of BC reception counter for a printed copy.
POOllMUVN:OC Membership Applicati,,,
ogn _ __ _ _
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