4650 Sunset Blvd., #29 | Los Angeles, CA 90027 | 323.361.1700 | ambassadors@chla.usc.edu | CHLA.org/AMBASSADORS

Join the Junior Ambassadors

The Junior Ambassadors of Children’s Hospital Los Angeles are kids and teens from the community who support the hospital’s life-saving work. The program gives kids the chance to work together and become inspiring hospital representatives and fundraisers. It’s a powerful model of kids helping kids.

Since 2012, Junior Ambassadors have given hope by speaking at various events, sharing their story, and inspiring more than $1 million in donations to support the hospital’s patients and families.

For more information, please visit CHLA.org/JRAMBASSADORS or contact us at 323-361-1700 or ambassadors@chla.usc.edu

PROGRAM HIGHLIGHTS Every member of the Junior Ambassadors Program is offered a special calendar of events and opportunities that allow kids to connect, learn, and inspire each other.

Welcome Kit Register to become a Junior Ambassador and receive your welcome letter plus official Junior Ambassadors shirt.

Action Day!Take Action! Whether it’s posting on social media or holding a car wash, let everone know about Children’s Hospital Los Angeles. #ActionDayCHLA

Junior Ambassadors ConferenceConnect, share, and kick-off a new year with fellow Junior Ambassadors as you learn more about the Hospital.

Junior Ambassadors CommitteeJoin a group of your high school peers for an extra leadership role within the program. Committee members are mentors and actively participate in the planning for the year.

Volunteer and Leadership OpportunitiesParticipate in a variety of activities that include public speaking, community outreach, and Holidays from the Heart.

Junior Ambassadors Celebration Celebrate the hard work and compassion of the Ambassadors family with a year-end party for all ages.

Philanthropy Workshop SeriesLearn how to become a community leader! Our Workshop Series highlights the different steps to becoming a successful fundraiser, spokesperson, and ambassador for Children’s Hospital Los Angeles (CHLA). Join us as we learn the fundamentals of giving back and how you are directly impacting the patients and families at CHLA.

The Series will include 5 workshops:1. What is Philanthropy?

2. Creating a Case for Support3. Speaker Training

4. Tour Training5. Developing a Fundraising Plan & Project

After completing all workshops, Junior Ambassadors will receive a Certificate of Completion

HOW TO BECOME A JUNIOR AMBASSADOR Kids of all ages can apply to become a member throughout the year. For more questions or to request a registration form, please contact the Ambassadors program at 323-361-1700 or ambassadors@chla.usc.edu

Junior Ambassadors Program Parent/Guardian Consent and Release Form

Junior Ambassadors are given an opportunity to be a representative and/or fundraiser for Children’s Hospital Los Angeles (“CHLA”). The Ambassadors are a group of supporters, both adults and children, who have the opportunity to become further engaged with CHLA. Children are encouraged to participate in many facets of the Program, including service and education. At the end of the calendar year, all Junior Ambassadors who pledge to be an Ambassador will be honored and thanked as participants. The Program is suggested for children 12 years of age or older. However, children of all ages are welcome to participate in the Junior Ambassadors Program (“Program”), and it is up to the parent/guardian to determine their child’s interest.

GENERAL INFORMATION

Child’s Name: Home Phone:

Address: City, State, Zip:

Age: Date of Birth: Child E-mail Address:

Parent Name(s):

Parent Work Phone: Parent Cell Phone:

Parent email:

Are you a patient family? Yes No

WAIVER AND RELEASE

You understand that CHLA does not require your child’s participation in this Program, CHLA may decide not to accept your child into

this Program, and CHLA may modify or end your child’s participation in this Program at any time in its sole discretion. You, your

child, and your heirs and assigns release and discharge CHLA and its directors, trustees, employees, staff, and volunteers from all

claims and liabilities arising from your child’s participation in this Program. You further agree to hold harmless and indemnify CHLA

and its directors, trustees, employees, staff, and volunteers for all costs and liabilities arising in connection with your child’s

participation in this Program. You are responsible for monitoring your child’s participation in this Program, and you and your child

agree to abide by this Consent and Release Form and all CHLA procedures and policies.

You certify the following: you are the parent or legal guardian of the child named above; you and your child are not agents,

representatives, or employees of CHLA; all information that you have provided to CHLA is correct; and your child has your

permission to engage in all the activities of this Program. You have read and fully understand this waiver and release.

Parent or Legal Guardian Signature: _______________________________ Date:____________

Please return this form to the AMBASSADORS Office at Children’s Hospital Los Angeles: 4650 Sunset Blvd., Mailstop #29, Los Angeles, CA 90027

Fax: 323.361.8651| AMBASSADORS@chla.usc.edu Questions? Please call 323.361.1700

Junior Ambassadors Registration Form

Name: ________________________________ Age: __________Date of Birth:______________ Grade: ______________ Name of School: ______________________________ Polo Shirt Size (please circle one): Youth/ Adult XS S M L XL Reason you want to become a Junior Ambassador: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Ways you would like to be involved (please check all that apply):

I pledge to help the patients and their families at Children’s Hospital Los Angeles by raising $1,000. I

would like to help fulfill my pledge by:

Creating a personal fundraising page at CHLA.org/SUPPORT

Collecting donations for activities that I accomplish, such as a sports goal, bike rides, walk-a-

thons etc.

Collecting donations for my birthday instead of gifts.

Holding a small fundraiser or event, such as a car wash, lemonade stand, craft boutique etc.

during the annual Junior Ambassadors Action Day or at another time of the year.

Other: _____________________________________________________________________

I am a patient family and would like to share my story

At CHLA events

Online

Print Publications

Print Name: ___________________________________________________________________ __________________________________________ ______________________________ Signature Date

Please return this form to the AMBASSADORS Office at Children’s Hospital Los Angeles:

4650 Sunset Blvd., Mailstop #29, Los Angeles, CA 90027 Fax: 323.361.8651| AMBASSADORS@chla.usc.edu

Questions? Please call 323.361.1700

MEDIA RELEASE

I grant permission to Children’s Hospital Los Angeles (“CHLA”) and people and companies that contract with CHLA to record, edit, use, reproduce, publish and distribute by way of photograph, video, film, and any other media (electronic or otherwise) the visual and audio likeness of me and/or my child. I also grant CHLA permission to use such likeness, my contact and demographic information, quotations, and any information provided to CHLA (such as Camp CHLA surveys, evaluations, applications, essays, and letters of recommendation) for news, educational, marketing, advertising, fund-raising, research, recruiting, and other purposes. Name of participant:_________________________________________________ Signature: _____________________________________________________________ (participant (if 18 years or older) or participant’s legal representative) Date:_________________ Print name: ___________________________________________________________ (participant (if 18 years or older) or participant‘s legal representative) Indicate relationship to participant: □ Self □ Parent □ Other legal representative (describe your authority to act on behalf of the participant) _________________________________________________ For Minor (Under Age 18) Participant: The legal representative that has signed above represents that he/she is authorized to act on behalf of the minor participant and agrees to all of the above. Witness signature: __________________________________________ Date:________________ Print name of witness: _________________________________________ Phone number ________________________________ Email address ______________________________

Please return this form to the AMBASSADORS Office at Children’s Hospital Los Angeles: 4650 Sunset Blvd., Mailstop #29, Los Angeles, CA 90027

Fax: 323.361.8651| AMBASSADORS@chla.usc.edu Questions? Please call 323.361.1700