Thank you for your interest in serving as an Illinois COVID-19 Prevention Ambassador.  You are vitally important in helping prevent and stopping the spread of COVID-19.

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* 1. Full Name

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* 2. Contact Information

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* 3. Race/ Ethnicity

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* 4. Please specify the racial/ethnic subgroup(s) you belong to.  For example, if you selected "Asian" in the last question, a possible response here could be Pakistani-American

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* 5. Gender

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* 6. What Illinois county do you currently live in?

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* 7. What is your current occupation?  What type of company/sector do you work in?  Tell us about the clients/communities you serve?

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* 8. What county do you work in and/or serve for work purposes?

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* 9. What social/ peer group(s) do you affiliate yourself with? 

For example, you can say "college student, member of a religious organization...etc)

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* 10. Why would you like to serve as an Illinois COVID-19 Prevention Ambassador?

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