2024-2026 INTEREST FORM | Not A Host™ Junior Ambassador STEM and Media Engagement Training Application

INTEREST FORM

Not A Host™ Junior Ambassador STEM and Media Engagement Training
Thank you for your interest in the Not A Host™ (#NAH) Junior Ambassador STEM and Media Engagement Training for middle school and high school students!! We are actively preparing for cohorts through 2026 and are happy to extend this opportunity for parents and youth to express interest at this time.

PLEASE NOTE:

***Families who complete this interest form will be the first to know the official launch dates for the next cohort as soon as they become available and will be invited to submit a full application."***

#NAH has reached over 500,000 North Carolinians with bilingual resources, with youth-led initiatives contributing to more than half of this impact. This six-month hybrid program combines STEAM and storytelling, offering STEM education and leadership development, and culminates in a multimedia campaign. The curriculum covers public health, systemic racism, medical distrust, COVID-19, social marketing, health communication and video production.

Overview of 15-session training:
- Five (5) virtual sessions (youth access online sessions on their own time and complete assignments and other activites at a pace that works for their schedule)
- Four (4) in-person training sessions
- Four (4) virtual media campaign planning sessions
- Two (2) day video production for youth-driven multimedia campaign
Each ambassador completing the virtual and in-person trainings AND video production will receive $500 as compensation for their work and an ambassador media resource kit.
PART 1 - PARENT/LEGAL GUARDIAN INFORMATION
Parent/Legal Guardian Name*

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

Confirmation Email
County of Residence*
Parent/Legal 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 ambassadorE-mail communicationSocial Media (Facebook, Instagram, etc.)Flyer posted in community (library, church, community center)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.

Clear
Medical/Health and Emergency Contact Information
Your child(ren)'s experience will include three (3) 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).
PART 2 - Ambassador Information

Parents/legal guardians may submit up to two (2) separate applications per household. If you have additional children interested in the program, please email us at office@pillarconsultingrtp.com.
Ambassador Name*

First NameLast Name
Ambassador Date of Birth*

MonthDayYear
Date
School District*
Ambassador School (2023-2024 School Year)
School District if Other
Ambassador Current Grade Level (2024-2025 School Year)*
Ambassador 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 Race/Ethnicity*

African-American/BlackAsian, Hawaiian-Pacific IslanderAmerican Indian/First PeopleHispanic/LatinxWhite/CaucasianOther
Ambassador Sex*

FemaleMaleNon-binaryTransgenderPrefer not to say
Ambassador 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 Allergies or dietary restrictions? Please type "none" if this does not apply.
Ambassador Medical conditions that may require special attention? (Example, Asthma--needs an inhaler). Please type "none" if this does not apply.
Are there any special supports or accommodations that Ambassador may need when participating in the scheduled in-person activities (onsite at the community center, offsite field trips)?

NoYes (please specify below)
Ambassador T-shirt Size

XSSMLXLXXL
Ambassador Face Mask Size

ML
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
Junior Ambassador 1 Agreement
The term of your training is six months. To be eligible for the $500.00 stipend, you are expected to complete a minimum of:
- Four (4) out of the five (5) virtual sessions in Teachable,
- Two (2) in-person sessions
- One (1) community service event
- Three (3) of the four (4) virtual planning sessions for health education campaign
- Upon completion of this work, ambassadors will be invited to attend the Ambassador Graduation Ceremony!
I have read the expectations required of #NAH Junior Ambassadors. I understand these duties and expectations and pledge to uphold them to the best of my ability.
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