Become an Ambassador Form

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Road Scholar Ambassador Online Application

Thank you for your volunteer spirit and support of Road Scholar. Road Scholar will proactively reach out to organizations in your community to arrange presentations for you. In addition, you are strongly encouraged to reach out to your contacts to organize presentations.

Your Personal Information

Title

First Name

Last Name

Street Address

City

State

Postal Code

Phone

Road Scholar Program Experience

How many Road Scholar Programs have you participated in?

Describe your best Road Scholar program experience (in about 25 words).

Tell Us About Yourself

What is/was your primary occupation or profession?

Are you a member of a Life Long Learning Institute?

YesNo

If yes, which Life Long Learning Institute are you a member of?

What are your special interests or areas of expertise?

What is your t-shirt size?

List at least one of your affiliations with your local community organizations and/or interest groups and your role (member, board member, director, etc.)

Affiliation

Role

Start Date

End Date

Hours per Week

Ambassador Program Expectations

How many hours per week do you expect to commit to the Ambassador program?

Do you have adequate means of transportation to conduct your volunteer duties?

YesNo

How many miles are you willing to travel for a presentation?

Please briefly describe (in 100 words or less) your expectations for the Ambassador Program.

In order for the Ambassador Program to be beneficial to both Road Scholar and you, our Ambassador, we expect a minimum of four presentations to be done by each Ambassador on an annual basis. Can you meet this commitment?

YesNo

Finally, how did you hear about the Ambassador Program?

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Ambassadors