Youth Ambassador Application

Contact Information

First Name

Last Name

Nickname

Address 1

Address 2

City

State

Zip code

Phone Number

E-mail

Additional Information

Date of Birth (MM/DD/YYYY)

Ethnicity

Hispanic/LatinxNot Hispanic/LatinxI prefer to not answer

Parent/Guardian First and Last Name

Parent/Guardian Phone Number

Parent/Guardian Email

Psoriatic Disease Information

Date of psoriasis diagnosis

Date of psoriatic arthritis diagnosis (if applicable)

What treatments have you used or are using to manage your psoriatic disease? (choose all that apply)

Over the counter products, e.g. coal tar, salicylic acid, lotionsTopical treatments, prescriptionPhototherapyOral treatments, e.g. Methotrexate, OtezlaBiologic treatments, e.g. Humira, EnbrelNot currently treatingOther

Other treatment

Who is your current dermatologist?

Who is your current rheumatologist?

Volunteer Information

What areas of volunteering are you interested in? (choose all that apply)

Other areas

Why do you want to be a Youth Ambassador?

NPF Youth Ambassadors are required to complete training sessions, a telephone interview with the program manager, and attend regular Youth Ambassador team meetings. They also sign a volunteer waiver form and confidentiality agreement (parent/guardian signature if under age 18). Are you willing to do this?

YesNo

Signature

By checking this box, it will serve as your signature.

Enter your full name here

Today's date

Plaque	Guttate
Inverse	Pustular
Erythrodermic	Palmoplantar
Scalp	Nail