Name:

Date of Birth (mm/dd/yyyy):

High School: Altoona High School Augusta High School Cadott High School Chippewa Falls High School Chippewa Falls McDonell High School Eau Claire Memorial High School Eau Claire North High School Eau Claire Regis High School Eleva-Strum High School Elk Mound High School Fall Creek High School Home School Association Immanual Lutheran High School Mondovi High School Osseo-Fairchild High School Stanley-Boyd High School

Year in School (Sophmore, Junior, Senior):

Address:

City:

Zip:

Parent or Guardian(s):

E-mail:

Phone:

How did you find out about the program? (all that apply)

Have you participated in this program before?

Answer the following questions if you have been a part of the Youth Ambassador program in the past.

What are your thoughts on the Youth Ambassador program?

What do you like about the program?

What could be improved?

Answer the following questions if you are new to the Youth Ambassador program.

What do you hope to learn?

What are you most looking forward to?

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