Ambassador Program Application Please provide the information for the individual applying to be an ambassador. Ambassador Name(Required) First Last Ambassador Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Ambassador Email(Required) Ambassador Phone(Required)The Ambassador is a:(Required) Self-Advocate Family Member Other Is the Ambassador 18 years or older?(Required)NoYesAmbassador Date of Birth MM slash DD slash YYYY Does the Ambassador have a Guardian and/or Power of Attorney?NoYesGuardian/POA Name First Last Guardian/POA Email Guardian/POA PhoneAre you completing this form for yourself or someone else?MyselfSomeone ElseYour Name First Last Your Email Your PhoneAre you and/or the Ambassador applicant familiar with any of The Arc's programs or services?NoYesWhich The Arc of Lehigh and Northampton Counties programs or services are you familiar with? The SPARC Program Agency With Choice The Arc's Advocacy Department Family Driven/Family Support Services Infusion of Inclusion 2.0 Select AllCheck the way(s) you are most interested in participating as an Ambassador for our chapter of The Arc?(Required) Sharing your story about using our programs and services Helping us at The Arc fundraisers and events Representing The Arc at a local event in our community Sharing your story to raise awareness about disabilities, inclusion, and acceptance Select AllWhat days of the week are you available to service as an Ambassador for The Arc? Weekdays Weekends Any day of the week What is your preferred availability for being an Ambassador for The Arc? Mornings Afternoons Evenings Select All
