Healthier U Ambassador Program Application
Before you complete this application, be sure to read about the role of a Healthier U Ambassador.

As a Healthier U Ambassador you agree to:
-Support the promotion of health and wellness among faculty and staff.
-Serve as a liaison to the Healthier U Executive Committee.
-Share information about Healthier U programs with your department, co-workers and colleagues.
-Provide Healthier U with departmental wishes/ideas.

Thank you for taking the time to complete this application. We look forward to following up with you.

Last Name
Your answer
First Name
Your answer
Department:
Your answer
Location:
In addition to the list of locations below, we recognize that there are other off campus worksites so please indicate so in the "Other" box if this applies to you.
Required
Name of Building
If not identified in the "location" list abve, e.g. hospital, health sciences center
Your answer
Campus phone:
Your answer
Email address:
Your answer
On-campus 4 digit zip?
For example z=4444
Your answer
Preferred T-shirt size
Do we have permission to contact your supervior?
Supervisor's Last Name
Your answer
Supervisor's First Name
Your answer
Supervisor's phone number
Your answer
Please provide a short description stating why you are interested in becoming a Healthier U Ambassador.
Your answer
Please describe any ideas or suggestions that you may have about promoting Healthier U to faculty and staff in your area.
Your answer
What is your work schedule?
Required
In addition to English, what other languages do you speak?
We recognize that some of our employees may not be fluent in English so in order to reach out to them we would like to know if you have proficiency in other languages.
Required
How proficient/fluent are you?
Check all that apply
Is there anything else we should know about you or that you wish to add? If so, please explain.
Your answer
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