Champions for Change Interest Form

Champions for Change Registration Form

REACH Community Coalition
Champions for Change: Roles & Responsibilities

Champions for Change support the Wellness Coalition REACH program by helping advance policy, systems, and environmental (PSE) changes that improve community health. Champions serve as trusted messengers, advocates, and connectors within their communities

Core Focus Areas
- Healthy Nutrition Promotion & Access
  - Support efforts that improve access to affordable, nutritious foods in community settings
  - Promote healthy eating messages and nutrition education initiatives
  - Help elevate community voices around food access, food environments, and equity
- Physical Activity Promotion & Community Design
  - Speak up for safer, more walkable, and activity-friendly outdoor spaces
  - Inform leaders and decision-makers about barriers to physical activity in the community
  - Support initiatives that encourage active living through community design and engagement
- Breastfeeding Promotion & Support
  - Advocate for breastfeeding-friendly policies, systems, and environments
  - Support awareness of lactation access, Baby Cafés, and breastfeeding resources
  - Help normalize breastfeeding and support families through community engagement
General Champion Expectations
- Inspire others to make healthy, sustainable changes
- Assist with planning and promoting REACH-related events (e.g., health fairs, Baby Cafés, community wellness activities)
- Attend at least two (2) REACH-supported events per year
- Share program updates and event information within their community networks
- Participate in quarterly Champion meetings to receive updates and provide feedback
- Help recruit and encourage additional community messengers to join the work
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you live in?
What type of work do you do?

Active Community MemberCommunity Health WorkerFaith-basedElected OfficialHealthcare workerPublic HealthLocal CelebrityTourismTransportationNon-ProfitOther
Which strategies do you align with most:*

Healthy NutritionCommunity Design in Physical ActivityBreastfeeding Continuity of Care

Click what areas and committee you are interested in being involved:

	Yes	No	Maybe	Any thoughts?
Healthy Voices Committee
Trailblazer Task Force
Milk Haven Committee
Milk Haven Committee Leadership
Tour of Wellness Vendor
Partnership/Contractor

Live Experience Advisory Group (LEAG) is a new program. If you are interested in being instrumental in helping to improve Breastfeeding Continuity of Care, please click below:

YesNoMaybeNeed more informationOther
Would you like to lead a county Milk Haven Committe?

YesNoI know someone who can lead it.Other
Please share with us who that potential team or leader is, so that we can contact them.
Why are you interested in volunteering as a Champion of Change?
As a Champion, how do you plan to assist our various programs?
How frequently do you use social media?

EverydayA few times a weekA few times a monthLess frequently
Which social media platforms do you use? Check all that apply.*

FacebookX (Twitter)LinkedInInstagramTikTokSnapchatOther
Please upload your headshot here. Your photo will be shared on The Wellness Coalition's website.*

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I name accept to be part of the Champions for Change and commit to participating and complying with the above statement.

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Champions for Change Registration Form