Become an Ambassador! Want to Become an Ambassador? If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required WANT TO BECOME AN AMBASSADOR?! You can complete an intake form below through our secure website, which will be sent automatically to our Amachi Program Coordinator, Kristina. Your information will be kept completely confidential. If you have any questions, feel free to contact Kristina at (412) 281-1288, option 5. NOTE: If you do not receive a "Thank You" message after submitting, your application was not submitted successfully. Please notify Kristina immediately. Ambassador Contact Information First Name * Last Name * Address * Apt # City * State * Pennsylvania ZIP * Phone * Phone Type * HomeCell Email Preferred Method of Communication * Home Phone Cell Phone Email N/A Parent/Guardian/Caregiver Information * Mr.Mrs.Dr.Ms. First Name * Last Name * Phone * Phone Type * Home Cell Email Personal/Demographic Information Date of Birth * Age * 1415161718 Sex * MaleFemale Race/Ethnicity * Hispanic or Latino? * YesNo Which family member(s) has ever been behind bars at any time in your life? * (Includes adoptive, in-law and step family members) MotherFatherGrandparentSiblingCousinAuntUncle School Information Name of Your School * Current Grade * 9th10th11th12th Graduation Year * Your Extra-Curricular Activities & Hobbies Select as many activities from the list below that interest you Arts/CraftsCookingBakingPhotographyTheaterHikingBasketballTrack & Field/Cross CountryVolunteeringComputer/ITVideo GamesDancingConcertsIce SkatingFootballMoviesMuseumsTravelRollerbladingGolfWatching TVShoppingBikingWalkingHockeyMusicReadingCanoeingBaseballSoccerSoftballTennisVolleyballCheerleadingWritingWatching SportsGardeningGoing to the parkSkiing Please list any other activities of interest not listed above Briefly tell us why you want to become an Ambassador * (In 50 words or less) T-Shirt Size S M L XL 2XL Jacket Size S M L XL 2XL Person submitting this form: * Self (teen)Parent/GuardianTeacher/CounselorCommunity member referring a teen