Health Ambassador Volunteer Application Form
Make a difference. Help your neighbors. Improve community health. Be the connection. Be the support. Be the change. Thank you for your interest in serving as a Health Ambassador! Your participation helps promote wellness, support community initiatives, and connect individuals to valuable health resources. Registration closes July 15th
Personal Information
Full Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address (Complete address- Please include zip code)
*
Which neighborhood do you live in? (Oaklandon, Fort Ben, Indian Lake, Lanesville, The Pike, Sunnyside, Geist's Edge, or The Ridge)
Availability
Program Dates: July 22nd to December 2nd, 2026. City events, drives, and the needs of the program will determine commitment
Please indicate your general availability:
Weekdays (Morning)
Weekdays (Afternoon)
Weekdays (Evening)
Weekends (Morning)
Weekends (Afternoon)
Weekends (Evening)
Specific Dates Available
Areas of Interest
Please select the areas where you would like to volunteer:
Community Health Events
Health Education & Outreach
Event Set-Up / Breakdown
Registration & Check-In
Wellness Workshops
Administrative Support
Social Media / Communications
Other
If Other, please specify
Skills & Experience (e.g., CPR/First Aid, healthcare background, community outreach, etc.)
Emergency Contact
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Consent & Agreement
I agree to serve as a volunteer Health Ambassador and understand I may be contacted regarding volunteer opportunities and updates.
*
I agree
Signature
*
Date
*
-
Month
-
Day
Year
Date
Additional Notes or Preferences
Submit
Submit
Should be Empty: