Youth Health Access & Social Mobilization Embassador (2025

Youth Health Access & Social Mobilization Embassador (2025–2026)
Your Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Do you need accommodation services in order to participate in this program?*

YesNo
Please enter what type of accommodation services do you need.*
Emergency Contacts*
Are you currently in High School?*
School Name*
Birthdate*

MonthDayYear
Date
How did you find the Health Access & Social Mobilization Ambassador program?*

Availability Information*

Why do you want to participate in this program?*
What are your skills?*
ie. Graphic Design, Social Media
Video Upload

Record a video of up to 2 minutes on your phone, with no editing or special production. You may speak in Portuguese, Spanish, or English. Find a quiet place with good lighting. Start by saying your name, city, and school, and then answer only the question below. Submit the link (Drive/YouTube as “unlisted”) in the form.

Question:

Who are you, and why do you want to be an EMBRACE Ambassador in Health Access and Social Mobilization? Briefly share something that motivated you.
File Upload*

If it is a link, please enter it in a Word document. Make sure that your video is not private.
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Applicant Signature*

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Youth Health Access & Social Mobilization Embassador (2025–2026)