WQPT PBS AMBASSADOR APPLICATION 2023
The information that you provide on and with this application form is collected under the authority of the Colleges Act and Freedom of Information and Protection of Privacy Act Section 33. It will be used to determine eligibility for the WQPT PBS Ambassador Program and for the administering of the program. 

Due to the nature of working with young children, all applicants will be subject to: Rock Island and Scott County Background Checks and State of Illinois Department of Children and Family Services Check.

If you have any questions, please contact Melissa Gravert: mgravert@wiu.edu or 309-764-2400 ext. 65026.
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NAME *
ADDRESS (INCLUDING CITY, STATE, ZIP) *
PHONE: *
EMAIL:
DATE OF BIRTH: *
Date
SCHOOL ATTENDING: *
PROGRAM OF STUDY:
ANTICIPATED GRADUATION DATE: *
Date
HAVE YOU VOLUNTEERED WITH WQPT PBS IN THE PAST? *
IF YES, IN WHAT CAPACITY AND WHEN?
PLEASE LIST SPECIAL SKILLS, STRENGTHS, OTHER LANGUAGES SPOKEN, ETC. *
PLEASE LIST STUDENT ORGANIZATIONS AND/OR EXTRA-CURRICULAR ACTIVITIES YOU HAVE PARTICIPATED IN. *
WHAT IS YOUR AVAILABILITY DURING THE SUMMER? *
ARE YOU INTERESTED IN WORKING WITH CHILDREN? *
ARE YOU COMFORTABLE WITH SPEAKING/PRESENTING IN FRONT A GROUP OF PEOPLE?  *
PLEASE LIST THE NAME AND CONTACT INFO FOR THE TWO REFERENCES FROM WHOM YOU WILL BE REQUESTING LETTERS OF RECOMMENDATION. PLEASE INCLUDE ONE FACULTY/INSTRUCTION AND ONE PERSONAL REFERENCE.  *
I certify that I have read and understood all the instruction and information on and with this application and understand the requirements of the WQPT PBS Ambassador Program. The information I have supplied is true and complete in all respects to the best of my knowledge. 
Typing your name and the date below is equivalent to signing your name to this document and therefore conveys your acknowledgement and authorization of the above statements.   
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