AMAAD Ambassador Application

AMAAD Ambassador Application

The AMAAD Ambassadors program offers peer-led support through strength-based recovery management services for LGBTQ people of color in South LA.

First Name *

Last Name *

Email Address *

Phone Number *

Street Address *

Address Line 2

City *

State *

Zip Code *

Date of Birth? (please include correct year) * +

Highest level of education? *

Employment Status *

Do you have a history of substance use? *

Yes

Which of the following substances do you have a history with? (Check all that apply) *

Have you ever received substance abuse treatment (residential or outpatient)? *

Yes

Have you ever participated in self-help groups? *

Yes

Please provide name & telephone number of reference. *

Provide name & telephone number of reference who can speak to your substance use recovery and/ or experience. *

Why are you interested in becoming an AMAAD Ambassador? *

What activities are of most interest to you? (Select all that apply) *