Member Application

WellCAT Ambassador
APPLICANT INFORMATION
Name:
Date of Birth:
Email:
Phone:
Wildcat ID:
Current address:
Summer Address:
Class/Year in School:
Expected Graduation Date:
Area of Study:
Current GPA:
T-Shirt Size:
EMPLOYMENT INFORMATION
Current Employer:
Employer Address:
Dates of Employment:
Position:
Identify any transferable skills:
Previous Employer:
Employer Address:
Dates of Employment:
Position:
Identify any transferable skills:
QUESTIONNAIRE
Describe your interest for becoming a WellCAT Ambassador.
Please list specific areas you would be interested in promoting
(i.e. Sexual Health Awareness, Nutrition and Body Image, Fitness, General Health).
Explain how your experiences & skills have prepared you for becoming a peer educator.
Describe your experience delivering presentations to the college student population.
Please list your other time commitments (i.e., academic work load, volunteering, and clubs).
STUDENT ORGANIZATION INVOLVEMENT
Example: (Organization, Office Held (if any), Dates In Group, Transferable Skills)
REFERENCES
Example: (Name, Relationship, Email, Phone Number)
ACKNOWLEDGEMENT AND SIGNATURE
By placing my initials here , I DO consent to have my photo used in marketing,
educational and promotional material, to include web site, display and printed brochures,
produced for Lafene Health Center.
I am aware of the campus student code of conduct and by signing this form I authorize Lafene
Health Center staff to verify my GPA and disciplinary status, I certify that this information is
correct and authorize references and employers to release information to Lafene Health Center
employees.
Electronic Signature (please type full name): 
Date: