The 2021-2022 Tobacco-Free Youth Ambassador Application
The Tobacco-Free Youth Ambassador Program is a statewide movement of youth, ages 12-21, who are committed to advocating, educating, mobilizing, and preventing tobacco and nicotine use in Rhode Island. Please reach out to 401-864-4422 or with any questions or to simply learn more! You can also visit for an overview of the program.
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What role are you applying for? *
What is your first and last name? *
(This name will be used on name tags, in social media posts, for events, in conversations, etc. Please put whichever preferred name you'd like to go by, whether that be a nickname or something completely different from your birth name.)
What are your preferred gender pronouns? *
ie: she/her/hers, he/his/him, they/them/theirs, she/they, he/they, I prefer not to identify; etc.
Gender: How do you identify? *
ie: nonbinary, female, male, I prefer not to identify; etc.
Cell phone number WITH area code *
ie. 401-864-4422 (type N/A if you do not have one)
Home phone number WITH area code *
ie. 401-864-4422 (type N/A if you do not have one)
Email *
Please do not use a school email, list a personal one you check often. ie:,, etc.
Full home address *
Street, town, state, zip, apt/unit # ie: 32 Smith Street, North Providence, RI 02865, Apt #221
Where do you live the majority of the time? *
Please include city/town and state. ie: at school in South Kingstown RI; at home in Providence, RI; I’m in transition but mostly living in East Providence, RI with my guardian; etc.
Do you live in any additional spaces? *
Please include city/town and state. ie: at Wilson College in Chambersburg, PN; at home in Providence, RI; with my dad in the summer in Narragansett, RI; with my sister on the weekends in Richmond, RI; N/A; etc.
Additional address location: *
If you're living on campus or at additional location(s) please provide full mailing address for each, or type N/A. ie: 1 Old Ferry Rd, Bristol, RI 02809
Where do you work? *
Please list all places of work and include the city/town and state for each. ie: Evergreen Nursing Home, East Providence, RI; Roger Williams University, Bristol, RI; Lincoln Creamery, Lincoln, RI; N/A; etc.
What school will you be attending in the upcoming year? *
Please include city/town and state. ie: Roger Williams University, Bristol RI; Cumberland High School, Cumberland RI; I won't be attending a school in the fall; etc.
What grade level will you be entering? *
ie: freshman in college; senior in high school; won't be in school; etc.
When is your birthday? *
ie: 09/01/2001
How old are you? *
Do you have a disability or any health conditions you'd like us to be aware of? *
List all or type N/A
Besides English, what other languages do you know? *
This could be anything from a 2nd language to a "partial understanding," you don't have to be perfectly fluent. Write N/A if you only know English.
What race do you identify with? *
ie: American Indian or Alaskan Native, Asian, Black, Native Hawaiian or Other Pacific Islander, White, I prefer not to identify; etc.
What ancestry do you identify with? *
ie: Armenian, Brazilian, Canadian, Chinese, Dominican, English, Filipino, French, French Canadian, German, Greek, Indian, Irish, Italian, Japanese, Liberian, Mexican, Polish, Portuguese, Puerto Rican, Scottish, Russian, I prefer not to identify; etc.
What ethnicity do you identify with? *
ie: Hispanic or Latino, Non-Hispanic or Non-Latino, I prefer not to identify; etc.
Are there additional groups you identify with? *
ie: Religion (Jewish, Muslim, Catholic, Agnostic, etc), Sexuality (asexual, bisexual, gay, heterosexual/straight, lesbian, pansexual, queer), I prefer not to identify, etc.
Why do you want to become an ambassador? *
What do you bring to this program to help move towards a tobacco-free Rhode Island? *
ie: skill sets, past experiences, etc.
What do you hope to gain from your involvement in this program? *
How did you hear about this program? *
ie. previous ambassador; e-newsletter; my prevention coalition; at an event; on social media; a friend; a teacher; etc.
Do you have any questions for us? *
If yes, please list them; if no, type N/A
Is there anything else we should know about you? *
If yes, please list them; if no, type N/A
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