State Ambassador – The Birth Buddy

State Ambassadorship Program Application Form

Full Name

Email Address

Phone Number

City

State

Professional Title or Role (if applicable)

Which best describes your current role? (Select all that apply)

Public Health Professional Doula Nurse Educator Social Worker Student/Early-Career Professional Community Organizer Parent with lived MCH experience

Briefly describe your background in maternal and child health (MCH)

Do you have experience working in or with underserved communities or maternity care deserts? (If yes, please describe)

Why do you want to become a Birth Buddy State Ambassador?

What does equitable access to maternal and child health mean to you?

How does your personal or professional journey connect with Birth Buddy’s mission?

What MCH challenges do you see in your local area that you’d like to address?

Do you have an idea for a capstone project that could meet a real need in your community? If yes, please describe your idea

How would you engage local voices and partners in your work as an ambassador?

Which community platforms, events, or networks would you use to raise awareness about Birth Buddy?

Are you comfortable using digital platforms and tools to share MCH resources?

Yes No

What do you hope to gain from this ambassadorship?

How do you plan to continue supporting MCH work beyond this program?

Upload Resume or CV

Letter of Support or Recommendation (optional)