Student Well-Being Ambassador Application

Student Well-Being Ambassadors are youth dedicated to the positive promotion of mental health and wellness across Utah schools and communities.

Name

First Name

Last Name

Pronouns (she/her, he/him, they/them, etc.)

Pronouns are used in place of a proper noun (like someone’s name). We use pronouns most often when referring to someone without using their name. Example: Have you heard from Tom? He hasn’t texted me back all day. He is the pronoun.

Student's Email

Student's Phone Number

(###)

###

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Student's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of School

Grade: 9th-12th

Current GPA: 2.5 or higher

Understanding of Guardian Approval: I understand that I must have parental approval to participate in this program

I Understand

Guardian's Name

First Name

Last Name

Guardian's Email

Guardian's Phone Number

(###)

###

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Understanding of Faculty Mentor Approval: I understand that I must have faculty mentor to participate in this program. This can be a teacher, coach, counselor, etc.

I Understand

School Mentor's Name

First Name

Last Name

School Mentor's Email

If you have any difficulty filling out this form please contact:

Grecia Corona (she/ella)

grecia.corona@utah.edu