Champions for Change Interest Form

Champions for Change/Trusted Messenger Interest Form

REACH Coalition
Thank you for your interest in volunteering to become a Champions for Change for our REACH Programs!

Champions of Change will:
- Assist the Wellness Coalition REACH program on how we can make changes for a Healthier Community.
- Inspire others to Make Healthy Changes
- Speak up for safer places to be active in the outdoors.
- Inform leaders and decision-makers about health issues facing the community.
- Assist with promoting healthy nutrition promotion, physical activity promotion and access, breastfeeding promotion, and access to adult vaccination uptake.
- Help with upcoming event planning.
- Attend at least 2 events (vaccination clinic, "A Tour of Wellness" health fairs, Baby Cafes, Breastfeeding Summit, Adult Vaccination webinars, etc.)
- Share updates and event information in their community circles.
- Attend quarterly meetings to discuss updates and events and provide feedback
- Are encouraged to recruit additional messengers
Please answer the following questions about the position, and we will be in touch with the next steps.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you live in?
What type of work do you do?

Active Community MemberCommunity Health WorkerFaith-basedElected OfficialHealthcare workerPublic HealthLocal CelebrityTourismTransportationNon-ProfitOther
Which social media platforms do you use? Check all that apply.*

FacebookX (Twitter)LinkedInInstagramTikTokSnapchatOther
How frequently do you use social media?

EverydayA few times a weekA few times a monthLess frequently
Which strategies do you align with most:

Healthy NutritionPhysical ActivityBreastfeedingAdult Vaccination
Why are you interested in volunteering as a Champion of Change/Trusted Messenger?
What could you do as a messenger to assist with the projects?
Please upload your headshot here. Your photo will be shared on The Wellness Coalition's website.

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I name accept to be part of the Champions for Change and commit to participating and complying with the above statement.

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Champions for Change/Trusted Messenger Interest Form