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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)
Submit Application
