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2019 Healthy Active Arkansas Ambassador Training

Healthy Active Arkansas Community Ambassador Training

Saturday, September 21, 2019

10AM-2:00PM

Arkansas Department of Health - Auditorium - 4815 West Markham, Little Rock, AR 72205

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* 1. Contact Information

First and Last Name

Cell:

County:

School Name (if applicable):

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* 2. Are you a bilingual community health worker

Yes

Other (please specify)

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* 3. Pageant Affiliation

N/A

Miss Arkansas or MAOT Prelim

Miss Teen Promise

Mrs. Arkansas International

HBCU Campus Queen or King

College Pageant Winner or Participant

Other (please specify)

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* 4. School Affiliation (if applicable)

SGA Officer

Future Farmers of America (FFA)

Family, Career and Community Leaders of America (FCCLA)

Future Business Leaders of America (FBLA)

Other (please specify)

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* 5. Classification (if applicable)

High School Junior

High School Senior

College

Graduate School

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* 6. Are you a member of a sorority or fraternity?

Yes (Specify organization in other)

Other

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* 7. Do you have a disability?

Yes

If yes, please list your disability and any accommodations or support you will need to participate in the training

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* 8. Do you have any dietary restrictions?

Yes

If so, (please specify)