Youth Ambassador Application

Youth Ambassador Program Information & Application

Thank you for your interest in becoming a part of the Tourette Association of America’s Youth Ambassador Program! Please apply below.

For Youth Ambassador Applicant:
Please complete and sign this application, and don’t forget to have your parent/guardian sign as well. Application must be completed by the Youth Ambassador applicant.
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender
- Male
- Female
- Non-Binary
- Transgender Female
- Transgender Male
- Other
Ethnicity/Race
- African-American or Black
- American Indian/ Alaska Native
- Arab or Middle Eastern
- Asian or Asian-American
- Hispanic or Latinx
- Native Hawaiian or Pacific Islander
- White, Caucasian, or European American
- Multiracial or Biracial
- Other
Grade*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Shirt Size (for YA only)*
- Small
- Medium
- Large
- X-Large
Do you belong to a local TAA Chapter?*
How did you hear about the TAA YA Program?*
Do you have a diagnosis of Tourette Syndrome?*
- Yes
- No
If no, do you know someone diagnosed with Tourette Syndrome? Please describe your relationship to them.
Do you have a sibling or family member that is a Youth Ambassador or Rising Leader? If so, what is their name and what year were they trained?
Please answer the next four questions to the best of your ability by indicating whether you Strongly Agree, Agree, Disagree, or Strongly Disagree in the statements below. These questions are general in nature and will not influence whether you are chosen to be a Youth Ambassador.
1. I am excited about what the future holds.*
2. I feel that I have all the tools I need to go out in the community and make presentations about TS.*
3. I feel comfortable sharing my story with groups of people in my community, including public officials.*
4. I plan to go to college or to a trade school/program after I graduate from High School. Please fill in the related question below as well.*
a. If strongly agree or agree, please share your plans regarding on campus or off campus living and why.
b. If disagree or strongly disagree, please explain why and tell us what your post HS plans are.
5. Have you been involved in any Tourette Association activities or events? If so, please list the event(s), what your involvement was, and how much time you have spent on the event/activity:*
6. Have you ever organized a school or community event? If yes, please list the event(s), what your involvement was, and how much time you have spent on the event/activity:*
7. What accomplishment are you most proud of, and why?*
8. We want to learn even more about you. In the section below, please tell us more about you:*
Please note: If you are chosen to become a YA, this information will be displayed publicly.
9. My favorite hobbies are....*
10. For fun, I like to….*
11. What makes me unique is…*
12. If you had to describe yourself in one word, what would that word be?**
13. Do you have any experience with public speaking? If yes, please explain:*
14. Would you feel comfortable presenting as a trained Tourette Association Youth Ambassador?*
Please note: If you are chosen to become a YA, this information will be displayed publicly.
Please upload a photo which the Tourette Association may use for print materials.*
Max. file size: 100 MB.
Video Submission: (optional) No more than 90 seconds
Max. file size: 100 MB.
Tell us in your own words why you want to be a Youth Ambassador and what being a Youth Ambassador means to you. Please include your name, age, and the state you live. You can also email video to [email protected] and include the subject line as Youth Ambassador Video Submission Please note: If you are chosen to be a YA your video may be displayed publicly.
My Story
Tell us your story and what you want people to know about you. What would you want the outside world to know about Tourette Syndrome? Please be sure to mention the following points:
- Tell us about your experiences with TS
- Do you, or someone you know, have a diagnosis of TS?
- Have you had any experiences telling people you have TS? Please explain.
- What experiences have you had with other people’s reactions to TS
- How do you see yourself as a representative for Tourette Syndrome?
- Why do you think you would be a responsible/effective Youth Ambassador?
- Please also tell us what you would like to achieve by being a Youth Ambassador?
- How do you envision the YA program having an impact in your life in 5-10 years?
Please note: If you are chosen to be a YA, your story will be displayed publicly. Also, note that Youth Ambassador stories will be edited and the final product may not be in the same format or contain all of the components submitted to the TAA.
Upload Personal Story (up to 500 words)*
Max. file size: 100 MB.
For Parent/Guardian:
Parent/Guardian Name(s):*
Parent/Guardian Email(s):*
Parent/Guardian Cell Phone Number(s):*
I have read the “Youth Ambassador Requirements” and am aware that my child is applying to be trained as a Tourette Association Youth Ambassador.
Initial*
If this application is accepted and my child is selected to attend Youth Ambassador Training at the Kellogg Conference Hotel in Washington, D.C., I understand that, as the guardian/parent who will be chaperoning my child, I am responsible for supervising my child at all times, including the time my child spends at the Kellogg Conference Hotel and any times when my child leaves the hotel for any reason including to attend Advocacy Day on Capitol Hill (if plans are changed and Advocacy Day is held in person). The event is being held in Washington DC, as such my child and I need to be aware of our surroundings at all times when outside of the hotel.
Initial*
If this application is accepted for attending the Youth Ambassador Training as an Additional Team rather than the Funded Team (please see Youth Ambassador Training Information Sheet), I understand that we will be responsible for all costs of the Training, including Training fees, travel, lodging and incidentals, and other program costs and materials.
Initial*
I give permission for my child's picture and name to be used by the Tourette Association as a Youth Ambassador in any and all publications:*
- Yes
- No
I grant permission to the Tourette Association to use my child’s name, hometown, and likeness with the following restrictions:*
Media Participation Release
I hereby irrevocably grant to the Tourette Association of America and to its employees, agents, and assigns, the right to photograph and/or video record and use pictures, silhouettes, videos and other reproductions of me and/or my children’s physical likeness (including potentially televised both locally and nationally) for educational, informational, promotional, charitable and fundraising activities for the Tourette Association and its Chapters and Support Groups and inclusion on, but not limited to the Tourette Association’s website, YouTube Channel and all other social media sites. I hereby certify and represent that I have read the foregoing and fully understand the meaning and effect thereof and, intending to be legally bound, I have hereunto set my hand.
Initial*
I have read the application in its entirety and understand the time commitment to prepare and train for the Youth Ambassador Training & Program.

For Myself

For Someone I Know

Through My Profession

For Myself

For Someone I Know

Through My Profession

Youth Ambassador Program Information & Application

For Youth Ambassador Applicant:

My Story

For Parent/Guardian: