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District 95 Club Ambassador Program
Dear Club Ambassador

Welcome to the District 95 Club Ambassador Program 2019-2020.  

Please give us your feedback about the Club you visited between July 1, 2019 and April 30, 2020
Please email Svetlana Breum, D95 IPDD if you have any questions regarding the form or program:
svetlanabreum@gmail.com

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Email *
Ambassador full name *
Ambassador Membership number *
Name of home club *
If you have multiple memberships, please only state the name of one home club.
ABOUT THE VISIT
This information will not only contribute towards your points on the Club Ambassador Program. A copy of your report can also be sent back to the club you visited to support their growth and development.
Please, mark one of the following choices?
Clear selection
Name of the visited club *
Area Number:
Division number:
District number:
Date of visit *
MM
/
DD
/
YYYY
Name of presiding officer at time of visit *
Presiding officer: Club Officer or Toastmaster of the evening
Email address of presiding officer at time of visit *
1 Point: With the permission from the club, please email a photo of you with the club’s banner or club members to svetlanabreum@gmail.com. Please include 'D95 CAP 2019-2020' in the subject of your email as well as the club name and when you visited.
Can we put the photo on District 95 social media?
Clear selection
2 Points: If you submit a photo AND 1 (one) minute video message/clip about club visit. Please email a photo and video-clip of you with the club’s banner or club members to svetlanabreum@gmail.com. Please include 'D95 CAP 2019-2020' in the subject of your email as well as the club name and when you visited.
Can we put the photo and video-clip on District 95 social media? *
3 Points: If you took on a role at the meeting, what was it? (If you did a speech instead, please leave blank) Function/Role Performed During Visit:
Choose here: *
Required
5 Points: If you gave a speech, please state the speech project/Path and title.
Enter here your answer: *
Additionally a copy of your responses will be emailed to the address you provided above.
What did you admire most about this club's practices?  What did the club do differently?
Mention one or two things you think would have made this meeting experience even better. Describe any practice that you observed which could help the visited club:
What best practice would you take back to your home club? Describe any practice that you observed which could help your home club.
ABOUT SUBMITTING THE FORM:                                                                                                                                     By participating in the District 95 Club Ambassador Program, I understand that I can only receive credit for visiting clubs of which I am not a member of on the date of my visit.  If I am serving as an Area, Division or District Director, I can only receive credit for visiting clubs outside of my Area, Division or District of responsibility, respectively.   *
Required
If you have any questions, please contact svetlanabreum@gmail.com. Please include “CAP D95 2019-2020” in the subject.
A copy of your responses will be emailed to the address you provided.
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