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2019-2020 LFA Florida Ambassador Application
Thank you for your interest in being an ambassador for the Lupus Foundation of America, Florida Chapter!
Training will take place Saturday, October 5 through Sunday, October 6 in Orlando, FL. Scholarships to cover partial hotel and travel are available on a limited basis.*
Please fill out the form below. Deadline for application is Monday, September 10 in order to be considered. You will be notified by Monday, September 17 of the committee's decision.
Name
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First
Last
Email
*
Phone
*
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Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Employer (if applicable)
Job Title (if applicable)
Gender
*
Male
Prefer not to disclose
Female
Other
What languages are you fluent in?
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English
Spanish
Creole
Other
Do you have lupus?
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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
Other
Which LFAFL events and/or programs have you attended in the past? (check all that apply)
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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?
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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?
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Yes
No
If yes, please name the organization and your involvement.
How far are you willing to travel if asked to represent LFAFL?
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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?
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Yes
No
How did you hear about the LFA Florida Ambassador Training?
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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?
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If chosen to be an ambassador, what are three things you would want to accomplish during your term?
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Are you comfortable public speaking?
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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?
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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?
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If so, please explain
What areas are you most interested in? (check all that apply)
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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?
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Yes
No
I have not been convicted, but I have pending charges against me
If yes or having pending charges, please explain.
Are you interested in applying for a limited hotel and travel scholarship (if selected, you would agree to share a room with another recipient)?
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Yes
No
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.