First Name
Last Name
Degree(s)
Are you affiliated with an Organization/Agency/Institution?
Yes
No
Organization Name
Please do not use abbreviations and spell organization name out
Organization Address
Organization Type
Adult Protective Services
Advocacy, Public Education and/or Policy
Aging and Disability Resource Center
Area Agency on Aging
Assisted Living
Case Management
Continuum of Care Agency
Home Health Services
Hospice or Palliative Care
Hospital or Doctor's Office
Independent Living
LGBT Service Provider or Org.
Memory Care Unit
NORC
Ombudsmen
Other
Other Professional Services
Professional Conference
Religious Center
Residential Only
School or University
Senior Center
Senior Health Insurance Assistance Program (SHIP)
Senior Medicare Patrol (SMP)
Senior Services Division (gov't)
Short-Term Rehabilitation
Skilled Nursing/Nursing Home
State Unit on Aging
Supportive Housing Services
Veterans Affairs
Email Address
Phone
How did you hear about the Education Ambassador Program
Internet Search
From a friend/colleague/other acquaintance
At a conference or at a workshop
Through an email
Other
Did you learn about the Education Ambassador Program from a National Resource Center on LGBT Aging training?
Yes
No
Which trainer?
Please describe your personal/professional experiences as it relates to working with older adults?
Please describe your personal/professional experiences as it relates to working with the LGBT population?
If relevant, please specify which populations in particular (lesbian, gay, bisexual, and/or transgender)
Please read the following three statements and signal your agreement by checking each box
By registering to become an Education Ambassador I agree:
To be available to give presentations in my area
To provide feedback on my presentations through the online survey
Opt-in to General SAGE eNews
By opting in you agree to receive general electronic communication from SAGE not specific to the NRC.
By submitting this request you agree to receive NRC specific communication from SAGE