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Goals of Care Coalition of New Jersey Ambassador Interest Form
Fill out this brief form to learn more about the Ambassadors program. You'll hear from us soon. Thank you for your interest!
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Please enter your name (including credentials, if applicable)
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Please enter your email address
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Your answer
Please enter your phone number
Your answer
All Ambassadors will receive a package with education materials, and other materials. Please fill out the address for these items to be shipped to you.
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What organization do you work for?
Your answer
What is your job title?
Your answer
Do you have training in palliative care, or other experience with people with serious illness and/or palliative care services?
Little to no experience
Personal experience as a caregiver or someone experiencing serious illness
Professional experience and/or training
How did you hear about the Ambassadors program?
Your answer
What communities do you identify with? We're interested in people with diverse community connections to become Ambassadors.
Your answer
Are you comfortable delivering health education to people and their families? Please share any relevant prior experience.
Your answer
Are you able to make a commitment through the end of 2026 to receive training and to deliver 4 or 5 community presentations?
Yes
Maybe - I need to learn more
No
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