EmailMe Form - 2021 LFA Florida Ambassador Application

EmailMeForm

Name *
First Last
Date of Birth *
MM / DD / YYYY
Email *
Phone *
### - ### - ####
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Employer (if applicable)
Job Title (if applicable)
Which of the following most accurately describe(s) you? *
Male
Prefer not to disclose
Female
Other
What is your ethnicity? *
Hispanic
Non-Hispanic
Prefer not to disclose
What race do you most identify with? *
Black or African American
White
Native Hawaiian or Pacific Islander
Asian
American Indian or Alaskan Native
Prefer not to disclose
What languages are you fluent in? *
English
Spanish
Creole
Other
Do you have lupus? *
Yes
No
If yes, what year were you diagnosed?
If no, what is your connection to lupus?
I am a caregiver of someone with lupus
I know someone with lupus
I have lost someone to lupus
I do not have any connection to lupus
I am a healthcare provider
Social Media
Please list your social media account names
Instagram
Facebook
Twitter
TikTok
Other
Which LFAFL events and/or programs have you attended in the past? (check all that apply) *
Walk To End Lupus Now
Seminar
Support Group
Teleconference
Advocacy Event in Tallahassee
Advocacy Event in Washington, DC
I have organized a 3rd Party Fundraiser
I have never attended a LFAFL event
How long have you been involved with LFAFL or any of our affilates? *
Less than one year
1-2 years
3-5 years
More than 5 years
This would be my first time being involved with LFAFL or it's affilates
If you were involved with a LFAFL affiliate, please list their name.
Have you ever been affiliated with another non-profit, including another lupus organization? *
Yes
No
If yes, please name the organization and your involvement.
How far are you willing to travel if asked to represent LFAFL (post pandemic)? *
Less than 20 miles
Up to 40 miles
Up to 50 miles
Up to 75 miles
Up to 100 miles
More than 100 miles
Are you available on occasional weekends to represent LFAFL? *
Yes
No
How did you hear about the LFA Florida Ambassador Training? *
Social Media
A LFAFL Staff Member
Email/Newsletter
LFAFL Website
Someone I know was an ambassador in the past
Why do you want to be a LFA Florida Ambassador? *
If chosen to be an ambassador, what are three things you would want to accomplish during your term? *
Are you comfortable with public speaking? *
Yes
No
I don't have much experience, but I am willing to try
After proper training, would you be comfortable speaking to the media? *
Yes
No
Maybe
Do you have any relevant past experience and/or skills that you could utilize during your time as a LFA Florida Ambassador? *

If so, please explain
What areas are you most interested in? (check all that apply) *
Health Fair/Community Outreach
Fundraising events
Company Lunch and Learns/Presentations
Advocacy (visits to elected officials)
Medical Community
Social Media
Patient Support and Education
Have you ever been convicted of a felony? *
Yes
No
I have not been convicted, but I have pending charges against me
If yes or having pending charges, please explain.
By submitting this form and signing below, I certify that all statements made on this form are true, complete, and correct. *
Clear
Please use your mouse to sign (click and sign)
If you would like to recommend a potential LFA Ambassador, please include their name and contact information below.

Social Media