Not A Host™ Junior Ambassador STEM and Media Engagement Training

Not A Host™ Junior Ambassador STEM and Media Engagement Training

APPLICATION FOR ADMISSION
Thank you for your interest in the Not A Host™ (#NAH) Junior Ambassador STEM and Media Engagement Training for high school students!! Wake County Department of Health and Human Services has partnered with Dr. Bahby Banks (Pillar Consulting) to conduct a free training program focused on STEAM, public health, health literacy, mass communication and health equity.

This application consists of two parts:
- PART 1: Application which should be completed by a parent/legal guardian and
- PART 2: Essay which should should be completed by the ambassador(s) interested in the program.
PART 1
Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Mobile Phone #*
Please enter a valid phone number.
Parent/Legal Guardian Email*

Confirmation Email
Parent/Legal Guardian Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about the Not A Host™ Junior Ambassador STEM and Media Engagement Training?*

Current parent/ #NAH ambassadorHealthLit4WakeEl CentroWake County 4-H Youth DevelopmentE-mail communicationSocial Media (Facebook, Instagram, etc.)Other
Parental Consent to Participate in Program
Not A Host™ Junior Ambassador STEM and Media Engagement Training is six-month program that consists of 12 sessions that highlight the root causes of disease, as well as basics of public health, COVID-19, informed decision-making and health communication. This training is not simply vaccine education. It is specifically designed to educate young people about structural and systemic racism, medical distrust and informed-decision making as it relates to COVID-19 prevention.

After completing the hybrid junior ambassador training, ambassadors will work with the Pillar Consulting team to create public health messaging and plan/attend at least one in-person service learning event in Wake County. #NAH Ambassadors completing the program in its entirety will earn total of $500.
As part of the foundational training for the ambassador training, your child(ren) will learn how their body fights against germs (like bacteria and viruses) and how these germs infect humans. S/he will learn about human body systems including: skeletal (bones), cardiovascular (heart), nervous (brain), immune (cells), or reproductive (sexual) system.*
Your child(ren) also will learn about racism as it relates to mistrust in medicine and research, and topics including the Tuskegee Syphilis Study and Henrietta Lacks. As a result, s/he may be exposed to information about how syphilis is spread through sexual contact.*
I hereby warrant and represent that I am the parent or legal guardian of the minor child(ren) enrolling in the Not A Host™ Junior Ambassador STEM and Media Engagement Training. *

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Our parents LOVE being involved with our ambassadors! Are you interested in volunteering for in-person events taking place on the following dates? If yes, select date(s) that you are available. If no, please proceed to the next section.

Kick Off Session: TUES, JAN 23, 2024, 6-8pmHealth Literacy Session: TUES, MAR 19, 2024, 6-8pmField Trip to Wake County Human Services: TUES, APRIL 10, 2024, 10am -3pmGraduation CeremonyGraduation Ceremony: SAT, JUNE 15, 2024, 6 – 8pm
Medical/Health and Emergency Contact Information
Your child(ren)'s experience will include four (4) in-person sessions and one (1) service event in the community. Our team takes every measure to ensure your child(ren)'s safety during in-person events, and we want to make sure we have someone on file if we cannot reach you in the event of an emergency.
Emergency Contact Name*

First NameLast Name
Emergency Contact Telephone Number*
Please enter a valid phone number.
In the event of an emergency in which I or my other emergency contact cannot be contacted, I agree to allow emergency medical staff and the #NAH program staff to take appropriate action to best serve the interest of my ambassador(s). *
Ambassador Information

Parents/legal guardians can submit (2) applications per household. If you have more children interested in the program, please email us office@pillarconsultingrtp.com.
Ambassador 1 Name*

First NameLast Name
Ambassador 1 Date of Birth*

MonthDayYear
Date
Ambassador 1 School (2023-2024 School Year)*
School if Other
Ambassador 1 Current Grade Level*
Ambassador 1 Email*

Confirmation Email
Ambassador 1 Mobile Phone NOTE: All communication and updates will be sent directly to youth through GroupMe. If your child does not have a mobile device, please enter your mobile #*
Please enter a valid phone number.
Ambassador 1 Race/Ethnicity*

African-American/BlackAsian, Hawaiian-Pacific IslanderAmerican Indian/First PeopleHispanic/LatinxWhite/CaucasianOther
Ambassador 1 Gender at Birth*

FemaleMale
Ambassador 1 Preferred Pronouns We aim to respect the pronouns and names of students that matches their gender identity.*

he/him/hisshe/her/hersthey/them/theirs
Ambassador 1 Allergies or dietary restrictions? Please type "none" if this does not apply.
Ambassador 1 Medical conditions that may require special attention? (Example, Asthma--needs an inhaler). Please type "none" if this does not apply.
Ambassador 1 T-shirt Size*

XSSMLXLXXL
Ambassador 1 Facemask Size*

ML

Ambassador 2 END
CONDITIONS FOR ENROLLMENT
The mandatory #NAH Junior Ambassador Training Welcome and Orientation Meeting for Parents and Ambassadors will be held on Tuesday, January 16th from 6:00 - 7:30pm. My child(ren) is/are not enrolled in the program until we have attended this orientation and completed the final required forms for participation.*

YesNo
My child's email address for access into the virtual learning system (Teachable) and receipt of communication cannot be changed after submission of this application.*

YesNo
MEDIA RELEASE

I hereby grant Pillar Consulting permission to use, re-use, exhibit, distribute, or publish my and/or my child’s testimonials, images, artwork, portraits, pictures or videos for any purpose including but not limited to illustrations, art, videos, promotional materials, editorials, advertising, publications, websites or web content, all without any compensation. I understand that any images, videos or artwork may be used at exhibits and may identify me and/or my minor child. I relinquish any right that I may have to inspect, examine or approve any completed product or products or any written or electronic copy or other printed matter that may be used in conjunction with any of the foregoing. I understand and agree that all materials containing the images or artwork of me and/or of my minor child shall become the property of Pillar Consulting, Inc.. I hereby release, discharge and agree to forever hold harmless Pillar Consulting, Inc., its legal representatives or assigns, and all persons or entities functioning under its permission or authority from all and any claims, demands or causes of action ensuing from or in connection with the use or publication of any of the foregoing including without limitation any claims for libel or invasion of privacy. This authorization and release shall inure to the benefit of the legal representatives, licensees and assigns of Pillar Consulting, Inc. and shall be binding upon me and upon my estate, my heirs and my legal representatives. I have read and fully understand the content, meaning and impact of the forgoing and represent that I am the individual named in this application. I agree that I am over the age of majority or that I am the parent or legal guardian of the minor child named in this application, am over the age of majority, and hereby consent to the foregoing on behalf of such minor child named in this application.
I have read and consent to the media release detailed above.*

YesNo