Ambassador Registration Form
 
About you
 
First Name*
 
 
Last Name*
 
 
 
Job Title*
 
 
Employer Name*
 
 
 
Employer Site*
 
 
Company Sector
 
 
 

The email address stated below should be used for all future communications with the Not Just Lab Coats Ambassador Team.
  
Email *
 
 
Preferred Contact Number*
 
 
 
Date of Birth*
 
 
 
 
Gender (Optional)
 
 
 
 
 
Location
 
In which geographical area(s) would you be willing to support activities?

Please add up to 4 locations
  
 
 
Preferred Location 1*
 
 
Preferred Location 2
 
 
 
Preferred Location 3
 
 
Preferred Location 4
 
 
 
 
By signing up as an Ambassador you confirm that you have the agreement of your employer to be involved in this programme and the employer will release you to attend the half day training session and to deliver activities with young people following your training (a minimum of 1 per year).

Also,  you are confirming that you are happy to be registered on our system as an ambassador.

  
Agree?*
 
Yes
No
 
 
 

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