Get Adobe Flash playerThis object requires Flash and Javascript installed and enabled



Heart Life Voice










"Through patience a ruler can be persuaded, and a gentle tongue can break a bone." Proverbs 25:15


Ambassador Application Form

To apply to become a Micah Ambassador, please complete all mandatory fields in the form below and click the 'Apply' button. 

* denotes required fields
Ambassador Application
Personal Details1
Title:*
First Name:*
Last Name:*
Age:*
I am:*
Address:*
Town/City:*
State:*
Postcode:*
Email:*
Phone 1:*
Phone 2:
Why do you want to be a Micah Ambassador?:*
Briefly tell us how you have been involved in social justice?:*
Are you involved in a social justice group or support group organised by an agency? If so, please give details2:
Group Details3
Name of the group that you are going to represent:*
Name of the leader to whom you will be responsible:*
Position of the leader4:*
Phone Number of leader:*
Declaration
I Agree with, and will ablide by the following conditions:*    
Online:
Spam Bot Email
Spam Bot Comment

© 2009 Micah Challenge. All Rights Reserved.