2022 Pennsylvania STEM Ambassador Program Application
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DEVELOPING STEM POLICY LEADERS IN PENNSYLVANIA

Application deadline: Friday, Jan. 21, 2022

Applying does not guarantee acceptance in the program. Applications will be reviewed for a well-rounded cohort and selection process will occur by Friday, Feb. 11, 2022.

All accepted 2022 STEM Ambassadors will be asked to sign a letter of agreement promising good faith efforts to fulfill the duties. Accepted applicants will participate in a two-day training, either virtually or in person, depending upon capacity and state pandemic guidance, during the last week of February or first week of March 2022.



The Pennsylvania STEM Ambassador Program is made possible through PSAYDN, with training support from the Education Policy and Leadership Center (EPLC) and STEM Education Coalition, and sponsorship from the Afterschool Alliance and Overdeck Family Foundation.
APPLICANT
Applicant Name *
Professional Title *
Organization *
Work Address *
Work City *
Work State *
Work Zip *
Work County *
Phone *
Email *
WORK LEGISLATIVE DISTRICT (WLD)
WLD House Number and Name *
WLD Senate Number and Name *
WLD Congressional Number and Name *
HOME LEGISLATIVE DISTRICT (HLD)
HLD House Number and Name *
HLD Senate Number and Name *
HLD Congressional Number and Name *
QUESTIONS
With what STEM-related/advocacy organizations are you affiliated? *
Describe your position within your organization. *
Describe your organization and the support it provides in STEM education and/or policy. *
How long have you worked for and/or supported STEM-focused organizations? *
Describe your experience and/or interest with STEM education and/or policies. (200 word limit) *
What is the reason for wanting to become a STEM Ambassador? *
I have (check all that apply): *
Required
Does your employer restrict you from talking to federal or state lawmakers about policy and/or funding issues? *
If yes, explain.
Describe any work you have done at the local, state or federal level to promote STEM education through education and/or workforce initiatives. *
REFERENCES
Reference 1 — Name, Professional Title, Phone, Email *
Reference 2 — Name, Professional Title, Phone, Email *
ENDORSEMENT
This section must be completed by supervisor/sponsor.

2022 Pennsylvania STEM Ambassadors are expected to participate in a two-day training the last week of February or first week of March either virtually or in-person based upon capacity limitations and state pandemic guidance, and a minimum of four monthly webinars. Ambassadors will be encouraged to participate in local legislative meetings as well as sponsored events in Harrisburg, including advocacy day events and legislative leadership meetings.

The program sponsorship of $800 is to be paid by the employing agency, private/public sponsor and/or the Ambassador, after acceptance into the program and no later than Friday, Feb. 25, 2022.

The signature affirms the employee's release time for full participation in the Ambassador Program, including acknowledgment of program cost and any travel costs associated with the Afterschool Ambassador Training (Harrisburg}, and other endorsed events.

If you have any questions, contact Winnie Black at wblack@csc.csiu.org.
Name *
Professional Title *
Date *
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Signature *
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