Email address:
*
First Name:
*
Last Name:
*
Home Street Address:
Home City:
Home State:
Home Zip Code:
Home phone:
Cell phone:
Work phone:
Employer:
What are your most immediate needs as a Newcomer that an Ambassador can address?
Please indicate your age
age 18-34
age 35-50
age over 50
prefer not to answer
Your ethnicity/race:
Languages you speak:
Please state any special accommodations needed under the American's with Disabilities Act?
One of the benefits of serving as a Diversity Focus Ambassador is having the opportunity to enrich your life by meeting a person that may be different from you in many ways such as gender, race, and ethnicity. However, we recognize that you may have a need that could be best met by a person with similar characteristics. These characteristics may or may not be present within the pool of available Ambassadors.
If ethnicity or race of your Ambassador is important to you, please state your preference:
Please indicate the age preference of your Ambassador:
age 18-34
age 35-50
over 50
no preference
Anything else we should know about you relative to this match?
For security, please type the word appearing to the right in the space below:
*
Submit
Should be Empty: