| WellCAT Ambassador |
| APPLICANT INFORMATION |
Name:
| Date of Birth:
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Email:
| Phone:
| Wildcat ID:
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Current address:
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Summer Address:
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Class/Year in School:
| Expected Graduation Date:
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Area of Study:
| Current GPA:
| T-Shirt Size:
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| EMPLOYMENT INFORMATION |
Current Employer:
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Employer Address:
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Dates of Employment:
| Position:
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Identify any transferable skills:
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Previous Employer:
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Employer Address:
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Dates of Employment:
| Position:
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Identify any transferable skills:
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| QUESTIONNAIRE |
Describe your interest for becoming a WellCAT Ambassador.
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Please list specific areas you would be interested in promoting
(i.e. Sexual Health Awareness, Nutrition and Body Image, Fitness, General Health).
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Explain how your experiences & skills have prepared you for becoming a peer educator.
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Describe your experience delivering presentations to the college student population.
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Please list your other time commitments (i.e., academic work load, volunteering, and clubs).
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| STUDENT ORGANIZATION INVOLVEMENT |
Example: (Organization, Office Held (if any), Dates In Group, Transferable Skills)
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| REFERENCES |
Example: (Name, Relationship, Email, Phone Number)
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| 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: |