Name*

First Last

Preferred Pronouns

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

Birth Date:*

Email Address:*

Phone Number

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have a diagnosed Learning Disability (LD) and/or AD(H)D?*

Yes
No
Unsure

Documentation of Diagnosed Learning Disability and/or AD(H)D

Part of what makes this program unique, is that the ambassadors working with our youth have a diagnosed learning disability and/or ADHD themselves. This allows the ambassadors to speak from experience and for them to be a role model for the youth in the Y2Y program. Please upload documentation below that identifies your learning disability and/or ADHD. This can include your psycho-educational assessment report, a Functional Limitations form, a previous IEP from high school etc. If you have questions about this or cannot upload your documentation below, please email the Y2Y Program Coordinator.

Drop files here or

Max. file size: 20 MB.

What personal experiences have you had that would make you a successful youth ambassador with the LDANR?

What does being a youth ambassador for the LDANR mean to you and how will you utilize the experience to benefit your local community?

Applicants must submit an explanation of what being a “Youth Ambassador'' for LDANR means to them, and how they will utilize the experience to benefit their local community. This can be done in any format, including but not limited to video, PowerPoint, art, or essay. This must be in the applicant’s own original work. If you are unable to attach the files to this application, please email your explanation to the Y2Y Program Coordinator and clearly state that you are submitting an explanation to attach to your Y2Y Ambassador application.

Drop files here or

Max. file size: 20 MB.

References

Please provide the names and contact information of two (2) professional references.

Name of Reference #1*

First Last

Relationship

(e.g., supervisor, manager, etc.)

Email*

Phone

Name of Reference #2*

First Last

Relationship

(e.g., supervisor, manager, etc.)

Email*

Phone

Terms and Conditions*

I hereby agree to comply with the Learning Disabilities Association of Niagara Region (LDANR)'s policy on violence and harassment. This is with the understanding that non-compliance may result in my removal from my LDANR position.
I understand that the information collected on this form will only be used to assess my eligibility for the position. This information will only be shared with LDANR staff.
I give permission to the LDANR to contact the persons listed as my references for the purpose of obtaining reference information. These persons are aware that the LDANR may contact them and have my permission to discuss information regarding my current and/or previous employment.

I have read and agree to the above terms and conditions.

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Y2Y (Youth to Youth) Ambassador Application

References

S.L.A.M. Camp Applications Open!

Ice Dogs Fundraiser

LDANR’s Trivia Night Fundraiser