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Civic Health Ambassador Application
Note: This form is currently closed. For opportunities to get involved, visit vot-er.org/careers
First Name
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Last Name
*
Email
*
Phone number
*
Pronouns
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Pick one or more pronouns, or select 'Custom' to write your own
Pronouns
A
he/him
B
she/her
C
they/them
D
Custom
What kind of pre-health student are you?
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Which college/university do you attend?
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What year are you?
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What year are you?
A
First year
B
Second year
C
Third year
D
Fourth year
Do you identify with any of the following groups?
Do you identify with any of the following groups?
First-generation college student
First-generation American
Bilingual/multilingual
People with disabilities
What organizations/communities are you a part of on campus?
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In 4-5 sentences, describe a specific skill or personal attribute which will help you build our Vot-ER movement.
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What excites you most about being a Civic Health Ambassador
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Select up to three options, or write your own. There are no wrong answers! 😀
What excites you most about being a Civic Health Ambassador
To learn from experienced community organizers
To make an impact in my community
To learn leadership skills
To help my patients, friends, and/or family register to vote
To connect with my classmates
To learn more about the relationship between voting and health as part of my pre-health training
Other (Write in)
Submit