Street Ambassador Intake Form

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C.R.I.P.S.

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🛡️Street Ambassador Intake Form

First name

Last name

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Where do you work - Company name and phone number?

Position

Do you have a Valid ID or Driver's License?

Yes

What City/Neighborhood You Represent?

Do you currently hold influence in your neighborhood?

Yes

Which group are you most comfortable working with? (choose one)

Why do you want to be a Street Ambassador for C.R.I.P.S.?

What kind of impact do you believe you can make?

What past experience do you have with outreach, mentorship, or street leadership?

What challenges in your community are you willing to stand up and address?

Youth Violence

Drug Abuse

Gang Recruitment

Poverty/Homelessness

Police Interaction

Community Healing

Other - Add Above

Are you currently affiliated with any groups, organizations, or movements?

Are you willing to go through a training process before becoming active in the field?

Yes

Do you agree to uphold the mission and message of C.R.I.P.S. at all times, even when it's hard?

Yes, I understand the responsibility of representing something bigger than myself.

Consent to Background Screening

I understand a background check may be required depending on my role.

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