Caregiver Resource Line Intake July 2024

Ambassador Program Application
The purpose of Arizona Caregiver Coalition Ambassadors is to represent the ACC within our community. Ambassadors will attend events and networking meetings to inform the public and organizations about our mission, vision, classes, and services. They will have the opportunity to raise awareness, motivate family caregivers, and encourage them to seek out resources.
Ambassador's Name:*

First NameLast Name
Ambassador's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ambassador's Phone Number:*
Please enter a valid phone number.
Ambassador's E-mail Address:*
example@example.com
Ambassador, do you speak any language other than English:

NoSpanishOther
Caring for person with:*

Dementia / Alzheimer'sDevelopmental DisabilityChronic ConditionUnknownOther
Ambassador's Family Member Name:*

First NameLast Name
How did you hear about us?*

Internet searchSocial MediaFamily MemberAgencyFriend/NeighborDES/DAASDDDMedia/News/RadioAAAAARPUnknownArizona Caregiver Coalition websiteOther
Your Role as a Family Ambassador
Please share your story:*
Tell us a little about yourself:*
What interests you about being a Family Ambassador? *
If you could share only one piece of advice, what would that message be?*
Is there a particular area you feel well versed in that you would share with others? *
Reasonable Accommodation
ACC Volunteers have the right to request reasonable accommodation to perform the essential functions of their position. Reasonable accommodation may be provided upon request. If you are a person with a disability and you would like to request reasonable accommodation, please contact Arizona Caregiver Coalition at

(888) 737-7494 or email info@azcaregiver.org

Equal Employment Opportunity Plan (EEOP) The Arizona Caregiver Coalition provides equal opportunity for all. We do not discriminate in any aspect of employment or service because of race, color, sex, national origin, age, disability, religion, sexual orientation, or any other improper criterion. In addition to federal law requirements, the Arizona Caregiver Coalition also complies with applicable state and local laws governing nondiscrimination in employment in Arizona
Upload a picture of yourself and your family member:*

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Should be Empty:

Ambassador Program Application

Your Role as a Family Ambassador