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Cooperative Extension: 4-H
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Maine 4-H STEM Ambassadors Application
Maine 4-H STEM Ambassadors Application
Step
1
of
3
33%
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Preferred mailing address for the Fall 2022 Semester.
Phone
*
Email
*
Enter Email
Confirm Email
University & Campus
*
UMaine - Orono
UMA - All Locations
UMF - Farmington
UMFK - Fort Kent
UMM - Machias
UMPI - Presque Isle
USM - All Locations
CMCC
SMCC
KVCC
What is your preferred method of teaching?
*
In-Person (must have access to reliable transportation)
Virtual
In-Person or Virtual, whichever best matches my schedule
Academic Program
*
Anticipated Date of Graduation
*
Were you in 4-H?
*
Yes
No
Where were you in 4-H?
Are you completing this program for class credit?
*
Yes
No
Which class and professor are you completing this program for?
Hidden
What grade level(s) of youth do you prefer working with?
Select All
Grades 3-4
Grades 5-6
Previous work or volunteer experience (list current or most recent first.) Include Employer or Organization, your position title or volunteer role, and the year.
*
In what STEM areas are you most interested, or comfortable sharing with youth?
*
Physical Science
Biological Science
Math
Engineering
Computer Science/Technology
Chemistry
Other
If you selected "other" in the previous question, please elaborate:
When are you available?
Check all that apply.
Monday
2:00 - 3:00 pm
3:00 - 4:00 pm
4:00 - 5:00 pm
5:00 - 6:00 pm
Tuesday
2:00 - 3:00 pm
3:00 - 4:00 pm
4:00 - 5:00 pm
5:00 - 6:00 pm
Wednesday
2:00 - 3:00 pm
3:00 - 4:00 pm
4:00 - 5:00 pm
5:00 - 6:00 pm
Thursday
2:00 - 3:00 pm
3:00 - 4:00 pm
4:00 - 5:00 pm
5:00 - 6:00 pm
Friday
2:00 - 3:00 pm
3:00 - 4:00 pm
4:00 - 5:00 pm
5:00 - 6:00 pm
References
List two - three persons not related to you who have a definite knowledge of your qualifications. Current faculty at your university are acceptable as references. Include complete addresses and email for each.
Reference 1: Name
First
Last
Reference 1: Email
Enter Email
Confirm Email
Reference 1: Phone
Reference 1: Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Reference 2: Name
First
Last
Reference 2: Email
Enter Email
Confirm Email
Reference 2: Phone
Reference 2: Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Reference 3: Name
First
Last
Reference 3: Email
Enter Email
Confirm Email
Reference 3: Phone
Reference 3: Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
May we contact other references suggested to us in the course of contacting the references listed above?
*
Yes
No
Please note: information received from any references will be considered as a part of your application.
In-Person Training
October 1 - 10:00 am - 12:00 pm
October 1 - 2:00 pm - 4:00 pm
October 3 - 2:30 pm - 4:30 pm
October 7 - 10:00 am - 12:00 pm
October 7 - 2:00 pm - 4:00 pm
Select all times that work for your schedule.
Have you ever been convicted of any crime other than a minor traffic violation?
*
Yes
No
If yes, please describe:
I authorize contact of listed references. I understand that misrepresentation or omission of facts requested is cause for non-appointment or termination as a Cooperative Extension volunteer. I agree toa bide by the expectations of Cooperative Extension and to fulfill the volunteer responsibilities to the best of my ability.
STEM Ambassador Signature
*
Please type your first and last name; understand that typing your name constitutes a legal signature confirming that you acknowledge and agree to the above statement.
Upon hitting submit, you will be directed to the required University of Maine Background Check. Please email 4-HScience@maine.edu and let us know when you have submitted that form.
Email
This field is for validation purposes and should be left unchanged.
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