EmailMe Form - 2022 LFA Southeast Region Ambassador Application

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)

What is your connection to lupus? *

If you selected you have lupus, what year were you diagnosed?

What is your race/ethnicity? *

What is your gender? *

What are your pronouns? *

He/Him/His

She/Her/Hers

They/Them/Theirs

If you speak a language other than English, please select the one you're most comfortable with.

Social Media

Please list your social media account names (If you do not have a social media account, please list N/A)

What social media do you use most often? Select all that apply.

How often do you post to your own social channels?

Instagram *

Facebook *

Twitter *

TikTok *

Other

Please indicate your past involvement with the Lupus Foundation of America by selecting any applicable items below. (check all that apply) *

How long have you been involved with LFA or any of our affilates? *

If you were involved with a LFA 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 LFA (post pandemic)? *

Are you available on occasional weekends to represent LFA? *

Yes

No

How did you hear about the LFA Florida Ambassador Training? *

Please share with us why you are interested in becoming an Ambassador, and any other relevant experience. *

If chosen to be an ambassador, what are three things you would want to accomplish during your term? *

Besides a cure, name something you would like to see occur in the next year for lupus? *

Besides a cure, name something you would like to see occur in 5 years for lupus? *

During your term, if you could only accomplish one thing to advance LFA's mission and vision, what would it be? *

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

What areas are you most interested in? (check all that apply) *

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.

Ambassador Volunteer Waiver

This Release and Waiver of Liability (the “release”) executed on this date by (“Volunteer”) releases the Lupus Foundation of America (LFA) and each of its directors, officers, employees, and agents. The Volunteer desires to provide volunteer services for LFA and engage in activities related to serving as a volunteer. Volunteer understands that the scope of Volunteer’s relationship with LFA is limited to a volunteer position and that no compensation is expected in return for services provided by Volunteer; that LFA will not provide any benefits traditionally associated with employment to Volunteer; and that Volunteer is responsible for his/her own insurance coverage in the event of personal injury or illness as a result of Volunteer’s services to LFA.

1. Waiver and Release: I release and forever discharge and hold harmless LFA and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the services I provide to LFA. I understand and acknowledge that this Release discharges LFA from any liability or claim that I may have against LFA with respect to bodily injury, personal injury, illness, death, or property damage that may result from the services I provide to LFA or occurring while I am providing volunteer services.
2. Insurance: Further I understand that LFA does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. I expressly waive any such claim for compensation or liability on the part of LFA beyond what may be offered freely by LFA in the event of injury or medical expenses incurred by me.
3. Medical Treatment: I hereby Release and forever discharge LFA from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a volunteer with LFA.
4. Photographic Release: I grant and convey to LFA all right, title, and interests in any and all photographs, images, video, or audio recordings of me or my likeness or voice made by LFA in connection with my providing volunteer services to LFA.
5. Other: As a volunteer, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of the District of Columbia and that this Release shall be governed by and interpreted in accordance with the laws of the State of the District of Columbia. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected.

By submitting this form and signing below, I certify that all statements made on this form are true, complete, and correct and I have read the disclaimer above. *

Clear