CIMCC TYA4TC: Tobacco Education Champion Registration

Interest Form

Native community members from Sonoma, Mendocino, and Lake Counties are encouraged to apply to the HONOR THE AIR program of the Tribal Youth Ambassadors for Tobacco Control Project of the California Indian Museum and Cultural Center (CIMCC).

The Project works to reduce Native Peoples' contact with secondhand smoke (SHS) and thirdhand smoke (THS) from commercial tobacco products and marijuana. Tobacco Education Champions will use Honor the Air educational materials, tools, and resources to help Native families in Sonoma, Lake, and Mendocino Counties create smoke-free homes.

Please note that Youth interested in becoming a Tobacco Education Champion must be at least 14 years old and have their parents/guardians' permission to participate.

Once this registration form is completed, a CIMCC staff member will contact you to be interviewed for this position in the program. We appreciate your interest in becoming a Tobacco Education Champion. For more information on this project, go to https://cimcc.org/tpp/.

Question Title

* 1. Contact Information:

Name

Tribal Affiliation

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

Question Title

* 2. Current occupation:

Question Title

* 3. Why are you interested in this position?

Question Title

* 4. How much time can you commit to this position?

4 months

6 months

12 months

Other (please specify)

Question Title

* 5. How much time per year can you allocate for this program?

25 hours

50 hours

100 hours

Other (please specify)

Question Title

* 6. What is your experience with commercial tobacco control projects? (Ex: cessation, smoke-free homes, smoke-free community policies)

Question Title

* 7. Why are you interested in supporting Native smoke-free homes?

Question Title

* 8. Do you have prior experience in coaching or mentoring?

Yes

Question Title

* 9. How do you want to benefit from being a Tobacco Education Champion?

Question Title

* 10. Do you have any questions or concerns?

Thank you for completing the Tobacco Education Champion application form! We will review the application in the next couple of weeks and get back to you if you have been selected to become a Tobacco Education Champion. For any questions on this application, contact Christy Garcia, Project Director, at projectdirectortya4tc@gmail.com, 1-866-904-3091.