2016 March for Babies Ambassador Family Application March for Babies Austin May 14, 2016 Old Settlers Park, Round Rock Deadline – November 15, 2015 We are seeking applications for the 2016 March for Babies Austin Ambassador Family. Many of our local families have been touched by the March of Dimes mission and have important stories to share with the community. The Ambassador Family will be chosen by a committee of 7 March of Dimes Staff, Volunteers, Board Members, and Mission Families who will review the applications and make a decision by December 1st. Commitment Being a March of Dimes Ambassador Family is both an honor and a commitment. As March of Dimes Ambassadors, a family takes on the following time commitments:  To schedule time to shoot a video about your mission story to be shared at the March for Babies Kick‐off and sent to all walkers.  To be present and to make brief remarks at the March for Babies Kick‐off event on February 11, 2016.  To be available pre‐event and morning of event for various media opportunities including print and social media interviews, radio shows and/or TV interviews.  To be present and to speak at various team kick‐offs or corporate meetings a few times per month during the months of January, February and March.  To be present and to speak at March for Babies on May 14, 2016 Is your family able to meet the above time commitments? Yes/No Ambassador Child’s Information (If you have multiple children that have been touched by March of Dimes, include information for each) Name: Age: Date of Birth: Name of School: Grade Level: Home Address: City: Home Phone: City of Birth: Interests and Activities: State: Zip Code: Place/Hospital of Birth: Candidate’s Mission Connection How was the child affected by the mission? Premature Yes/No Birth Defect Yes/No Infant Mortality Yes/No 1. If premature, please provide the following details: a. Due Date b. Weeks gestation at birth c. Reason for premature birth (please indicate if unknown) 2. If the child was born with a birth defect, please provide specific details: 3. If the child has passed away, please provide the following details: a. Due Date b. Weeks gestation at birth c. Reason for infant mortality (please indicate if unknown) March of Dimes has funded research of treatment and medications that may have helped improve the child’s health. Please indicated if any of the following was used: 1. Folic acid: Yes/No 2. Fetal surgery: Yes/No 3. NICU technology: Yes/No 4. Nitric oxide therapy: Yes/No 5. Prenatal care: Yes/No 6. Surfactant: Yes/No 7. Genetic counseling: Yes/No 8. Other (please describe): 9. If known, describe the role March of Dimes shared in the development of your child – NICU visits, funded treatments, local program or education: 10. Was your pregnancy, child’s birth and other health care your baby needed covered by insurance? (Please explain): 11. Delivering Physician Name: 12. Neonatalogist Name: Family Information Mother’s Name: Date of Birth: Occupation: Employer: Education: Other Interests: Father’s Name: Date of Birth: Occupation: Employer: Education: Other Interests: Other family members who live with candidate (siblings, grandparents, etc.): Name/Relation: Age: Name/Relation: Age: Name/Relation: Age: Volunteer History 1. Has the candidate and his/her family volunteered with or fundraised for the March of Dimes? 2. If yes, how long has the candidate and his/her family been March of Dimes volunteers? 3. Was the candidate ever a March of Dimes ambassador? Yes/No a. If so, for how long? 4. Please list any other volunteer roles held by the family: 5. Please list March of Dimes events that the family has participated in: 6. Has the candidate/family done media interviews? Yes/No Print Yes/No TV Yes/No Radio Yes/No 7. How and when did you first get involved with the March of Dimes? 8. What impact has volunteering had on you? 9. How has the mission of the March of Dimes affected you and your family? 10. What is your availability to make presentations throughout the year (individually, with the child or as a family)? 11. Is your family comfortable sharing your personal story and speaking to groups about your pregnancy and the medical challenges that faced your newborn? 12. Is your family comfortable sharing your story in the mass media, i.e. on television and in the newspaper? About the Child/Children: 1. Enjoys meeting people? Yes/No 2. Is talkative? Yes/No somewhat – depends on the situation… 3. Likes to have his/her picture taken? Yes/No * More candid shots than professional 4. Follows directions well? Yes/No 5. Is shy with strangers? Yes/No 6.
other (please describe): Please return completed application to: Katerina Kormas Echelon II 9430 Research Blvd. Suite 250 Austin, TX 78759 [email protected] Fax: 512‐477‐2788