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* 1. First Name

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* 2. Last Name

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* 3. Email

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* 4. Organizational Area

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* 5. Department Name

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* 6. How did you hear about the Wellness Ambassador Program?

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* 7. Why are you interested in becoming a Wellness Ambassador?

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* 8. Wellness Ambassadors are volunteers that create a health-minded community in UC San Diego Faculty and Staff. Will you be able to commit to a minimum of 1 hour per month as a Wellness Ambassador?

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* 9. What health and wellness programs or events would you like to see at UC San Diego?

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* 10. What topics/information would you like to learn about or discuss at meetings?

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