Community Ambassador, Expression of Interest Form

Ask Me, Change That Lasts
We collect this information from everyone we work with to make sure that our services are accessible to everyone in the community.  All the information in this form will be kept confidential and in line with our data protection policy.  The data will be stored with Mid-Ulster Women's Aid and Women's Aid Federation Northern Ireland.  The data collected will be anonymised for evaluation purposes and anonymous findings published. Consent to use your information for evaluation purposes is required in question 1.  If you do not wish to share your information please select no.


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* 1. I consent to my information being used for evaluation purposes.

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* 2. Full name

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* 3. Town/ City

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* 4. Postcode

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* 5. Contact number

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* 6. Date of Birth

Date

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* 7. E-mail address

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* 8. Which area are you applying for?

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* 9. Which training date would you like to apply for?

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* 10. This training is aimed at people who have a connection to local communities. This could take many different forms, for example in a volunteering/work role or through being involved in any networks, groups, activities and/or clubs etc. Please tell us about all your connections to the above area:

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* 11. In what spaces do you interact with people most in your day to day life (online and offline)?

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* 12. What kinds of people, groups and/or spaces do you hope to reach after becoming an ambassador? E.g. people within your place of worship, workplace, community group, gym class, mum and baby groups?

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* 13. How did you hear about the Change That Lasts Ask Me scheme?

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* 14. Why do you want to become a community ambassador?  Please tick all that apply

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* 15. We are committed to supporting ambassadors to attend the training whatever their experiences and to ensuring our training is as accessible as possible. Please let us know if there is anything we should know to ensure you are comfortable and get the most out of the training. This might relate to having a disability, a health condition, learning difficulties or if English isn't your first language and you need additional support. We will do our best to accommodate you.

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* 16. Which one of these best describes you?

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* 17. Do you identify as trans/ transgender or have a trans history?

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* 18. What is your age?

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* 19. Do you consider yourself to have a disability?

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* 20. If yes show list ( please tick any that could apply)

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* 21. How would you describe your ethnicity?

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* 22. Asian/ Asian British

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* 23. Black/African/ Caribbean background, please describe

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* 24. Mixed/ Multiple Ethnic Groups

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* 25. White

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* 26. None of the above

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* 27. Do you have a faith/ religion? ( Chrisitian, Muslim, Hindu, Spiritual, Rather Not Say, None

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* 28. How would you describe your sexual orientation?   (e.g. heterosexual/straight, gay woman/lesbian, gay man, bisexual, pansexual, asexual, I’d rather not say)?

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* 29. Do you have any caring responsibilities? ( Please tick all that apply)

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* 30. Please state your highest level of education

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* 31. Are you currently :

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* 32. Housing

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