Teen Ambassador Program

Thank you for your interest in the MCH Teen Ambassador Program. We are excited to continue this summer volunteer program. Before completing the application, please review the following Summer Teen Ambassador Program requirements:

• Must be enrolled in high school for the 2025-2026 academic year or a 2025 high school graduate.
• Submit a complete application, with all required paperwork by 5 p.m. CST on Monday, April 21, 2025.
• Commit to a consistent schedule of 3-hours of service, 3 days per week (Tuesday-Thursday, 9:30 a.m.-12:30 p.m.).
• Commit to weekly service between June 16 – July 25, 2025.* Ambassadors may miss up to two shifts. Missing additional shifts may result in removal from the program.
• Complete a health assessment which may include, but is not limited to: Health History, Latex Sensitivity Screen Tool, Hepatitis B Consent/Declination, Pneumococcal Vaccination Consent/Declination, Hepatitis A vaccine series, Communicable Disease Screening Tool, Drug Screen, Immunization Documentation, TB Skin Test.
• Applicants under age 18 must provide parent/guardian consent.

*We understand that family vacations are often scheduled during the summer months. Please note in your application if you have a previously scheduled trip. We will do our best to accommodate.

We will admit up to 25 Teen Ambassadors to the summer volunteer program. Please complete all required fields on this application and upload the requested essay. Once you have completed and reviewed the form, click the submit button at the bottom.

For more information, call 270-745-1215.

Teen Ambassador Program Volunteer Application 2025

Parental/Guardian Participation and Consent

I acknowledge I have participated in completion of this application.

For applicants under the age of 18. By checking this box, the users acknowledge that application completion, and participation in this program if selected, requires parental/guardian consent, and that the legal guardian is participating in completion of this application.
A legal guardian over the age of 18 must check this box and enter his/her name below, which constitutes an electronic signature.

Name of Parent or Guardian Granting Consent

First Last

Contact Information

Name(Required)

First Middle Last

Preferred Name

Nickname or preferred name

Address(Required)

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Home Phone(Required)

Cell Phone(Required)

Ok to text?(Required)

Yes

No

Email(Required)

Demographic Information

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Gender(Required)

Preferred Pronouns (Optional)

Grade Level(Required)

Current School(Required)

Social Security Number(Required)

Family Members Employed by Med Center Health(Required)

None

Sibling

Parent/Guardian

Other

Parent/Guardian Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Relationship (Parent or Legal Guardian)

Essay

Upload Your Essay(Required)

Accepted file types: txt, doc, docx, rtf, pdf, Max. file size: 5 MB.

Please explain how being accepted into this program will help advance your aspirations of working in a health-related field. Microsoft Word and PDF documents accepted. (500-word max)

Reference(s)

Counselor/Teacher Reference(Required)

Drop files here or Select files

Accepted file types: txt, doc, docx, rtf, pdf, Max. file size: 20 MB, Max. files: 2.

Please upload a reference from your guidance counselor and/or Medical Arts Pathway teacher. You may attach up to 2 references.

Additional Information

Schedule Conflicts

The Teen Ambassador Program will take place Monday June 16 through Friday July 25, 9:30 a.m.- 12:30 p.m. . Ambassadors are expected to attend each day. We understand that you may have a vacation planned with family. Please list any days/dates you know you aren’t available to attend the program.

Agreement

Consent(Required)

I understand that submitting this application form does not guarantee participation in the Teen Ambassador Program, and that there are certain qualifications I must meet including the acceptance of established volunteer policies and procedures before I can begin volunteering.
By submitting this form, I attest that the information I have provided on the form is true and accurate.

I understand that if selected I must complete and/or provide the following before beginning my volunteer work:

– MCH Employee Health Requirements.
– TB Skin Test (provided by MCH Employee Health)
– Current Immunization Record
– Background check (completed by MCH Human Resources)
– Computer Based Learning modules (to be completed after acceptance, but before June 16 start date. Will be sent by MCH Human Resources)

I agree

Signed Parent/Guardian Consent

(For participants under age 18.)

Name of Parent/Guardian

First Last

Parent/Guardian Phone

Parent/Guardian Email

Signature

Email

This field is for validation purposes and should be left unchanged.