Family Ambassador Nomination Form

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* 1. Contact Information

Name (first and last)

Address

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 2. Gender

Woman

Man

Transgender

Non-binary/non-conforming

Prefer not to respond

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* 3. Race (please select all that apply)

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

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* 4. Ethnicity (please select all that apply)

Hispanic

White alone, non-Hispanic

Black or African American alone, non-Hispanic

American Indian and Alaska Native alone, non-Hispanic

Asian alone, non-Hispanic

Native Hawaiian and Other Pacific Islander alone, non-Hispanic

Multiracial, non-Hispanic

Some Other Race alone, non-Hispanic (please specify)

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* 5. Please check all that apply. I am a…

Parent

Grandparent

Foster Parent

Kinship caregiver

Other (please specify)

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* 6. Number of children currently living in household

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* 7. Age of children currently living in household

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* 8. How did you hear about the Family Action Network? (Please provide the name of the organization that referred or nominated you)

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* 9. I prefer to be contacted by (select all that apply)

Phone Call

Text

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* 10. The best time of day to reach me is (select all that apply)

Mornings (8am-noon)

Afternoons (noon-5pm)

Evenings (5pm-8pm)

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* 11. I am able to attend the Family Action Network Launch on May 18, 2022 at the Ohio Statehouse in Columbus, Ohio (check one)

Yes

Unsure

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* 12. I am able to attend the three (3), 90-minute Family Action Network virtual trainings between April and May (please check one)

Yes

Unsure

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* 13. If other than English, what is your primary language?

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* 14. Do you have a need for an English language or ASL interpreter?

English Language Interpreter

ASL Interpreter

Other (please specify)

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* 15. I have reliable access to (select all that apply):

Smart phone or Computer

Internet connection or Wireless Data Connection

I need support to overcome technology or connectivity barriers (please specify needed support below)

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* 16. When I think about my family, the first word that comes to mind is:

Thank you! (Don't forget to click submit below)

A member of the Groundwork Ohio team will be in touch to inform you if you are selected to participate in the Family Action Network.

If you have questions please email FamilyAction@GroundworkOhio.org

Family Ambassador Nomination Form

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* 1. Contact Information

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* 2. Gender

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* 3. Race (please select all that apply)

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* 4. Ethnicity (please select all that apply)

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* 5. Please check all that apply. I am a…

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* 6. Number of children currently living in household

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* 7. Age of children currently living in household

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* 8. How did you hear about the Family Action Network? (Please provide the name of the organization that referred or nominated you)

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* 9. I prefer to be contacted by (select all that apply)

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* 10. ﻿The best time of day to reach me is (select all that apply)

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* 11. I am able to attend the Family Action Network Launch on May 18, 2022 at the Ohio Statehouse in Columbus, Ohio (check one)

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* 12. I am able to attend the three (3), 90-minute Family Action Network virtual trainings between April and May (please check one)

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* 13. If other than English, what is your primary language?

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* 14. Do you have a need for an English language or ASL interpreter?

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* 15. I have reliable access to (select all that apply):

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* 16. When I think about my family, the first word that comes to mind is:

* 10. The best time of day to reach me is (select all that apply)