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Ambassador Application

"*" indicates required fields

Ambassador Program

Application & Selection Process

Thank you for your interest in becoming a peer mentor Ambassador. There is a multi-step selection process:

Step 1: Complete Application
Step 2: Reference Check
Step 3: Two-Part Interview Process
Step 4: Training and Certification

*The selection process takes place on a quarterly basis.

Application

First Name*

Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Date of birth*

Month

Day

Year

Gender*

Veteran*

Race / Ethnicity*

Disability Type*

Injury Level / Description*

Date of Injury/Diagnosis*

Month

Day

Year

Cause of Injury*

Where did you attend Rehab?*

If Rehab not listed above: Where?

What areas are you willing to serve? (Check all the apply)*

Northridge (North LA)

Casa Colina (Pomona)

Rancho (Downey)

Cal Rehab (South LA)

Ballard (San Bernardino)

St. Jude (Brea)

Sharp (San Diego)

Long Beach Memorial

Long Beach VA

Cottage Rehab (Santa Barbara)

Palmdale Regional

St. Johns (Oxnard)

Tell us about yourself*

Why are you interested in being an Ambassador?*

What aspects of being a peer mentor relate specifically to your talents or interests?*

Share some of your successes since the onset of your SCI/D*

How would you rate your mental health?*

Poor

Moderate

Good

Excellent

Do you currently attend a Triumph SCI support group?*

If yes, which one?*

Did you have a peer mentor?*

If yes, discuss the most rewarding and challenging aspect of your peer mentor experience?*

If no, discuss what you wish someone could have shared with you to help improve your experience and recovery.*

How did you learn about Triumph?*

Upload a current full body picture of yourself*

Max. file size: 64 MB.

Upload a letter of recommendation*

Max. file size: 64 MB.

Hidden

Hidden: Form Date

MM slash DD slash YYYY

Hidden

Hidden: 01. Has a Disability?*

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