Yellow Lotus Collective Application
A program of Samaritan House
Name
*
First Name
Last Name
Preferred Name
*
Preferred Pronouns
*
Email
*
example@example.com
What grade will you be in for the 2026-2027 school year?
*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
What school will you be attending for the 2026-2027 school year?
*
Do you reside in Virginia Beach?
*
Yes
No
Would you be able to commit to attending after-school meetings once a week or once every two weeks for a majority of the 2026-2027 school year?
*
Yes, I am available once a week.
Yes, I am available once every other week.
Unsure
No
Please share other extracurricular activities or events that may impact your ability to attend Yellow Lotus Collective meetings.
Would you be able to provide your own transportation to the Samaritan House office? [2620 Southern Blvd, Virginia Beach, VA 23452]
*
Yes
No
I may need help navigating public transit to get to the Samaritan Houseoffice.
Please share any past experiences with volunteering or advocacy work.
Please share (minimum 150 words) why you are interested in becoming a Violence Prevention Ambassador.
*
You are welcome to attach a current resume or past recommendations you have received to complete your application
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