Ds Medical Outreach Ambassador Application
Thank you for your interest in becoming a volunteer with the Down syndrome Medical Outreach  Ambassador Program!  Families receiving a prenatal or birth diagnosis of Down syndrome do so with varying degrees of information. Often, OB doctors and Labor and Delivery hospital units have little knowledge of or information about Down syndrome. Having good, current information about Down syndrome, and about the programs and     supports available for families, can make a big difference in the lives of babies with Down syndrome and their families. To reach the health care professionals who can provide this information, we need your help!  Please read thoroughly and complete application to apply to the volunteer with us.

Ds Medical Outreach Ambassador Program Expectations:
- Serve as an ambassador for the Down syndrome community and Down Syndrome Indiana
- Be a leader in the community
- Have knowledge about local and national Ds resources
- Have basic understanding of services offered by Down Syndrome Indiana
- Have basic understanding of DSI’s Medical Outreach Initiative
- Develop relationship with your local/assigned hospital’s Labor & Delivery department and local OB/GYN offices (using Down Syndrome Indiana business cards)
- Make quarterly visits to local hospital’s L&D department with materials
- Make quarterly visits to local OB/GYN offices with materials
- Offer Medical Outreach Training to healthcare providers
- Stay in regular contact with DSI/The Lucky Mama Project
- Complete contact log and submit quarterly
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Email *
Name *
Address *
City *
Zip *
Phone Number *
Name of loved one with Ds *
Your relationship to person with Ds *
Birthday of loved one with Ds *
Mother of person with Ds *
Father of person with Ds *
Tell us about your Ds diagnosis experience *
Why do you want to be a Ds Medical Outreach Ambassador *
Tell us about your professional background *
Tell us about your comfort level with public speaking *
Can you commit to quarterly visits to providers (keep in mind that this visits will need to take place Monday - Friday during business hours)? *
What hospital systems do you have a relationship with (ie: regularly visit, delivered at, employed by, family connection, etc)? Please include the hospital, city located, and your relationship. *
Check which counties you would be willing to be assigned
Jay County
Randolph County
East Central
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Franklin County
Ripley County
Fayette County
Southeast
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Rush County
Shelby County
Fayette County
South Central
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Madison County
Deleware County
Grant County
Henry County
Northeast
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Fulton County
Cass County
Pulaski County
Miami County
Howard County
North Central
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Tippecanoe County
Boone County
Northwest
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Vermillion County
Vigo County
Sullivan County
Southwest
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Hendricks County
Morgan County
West Central
Check which counties you would be willing to be assigned
Marion County (south)
Johnson County
Indy Area South
Check which counties you would be willing to be assigned
Marion County (north)
Hamilton County
Indy Area North
Check which counties you would be willing to be assigned
Marion County (east)
Hancock County
Indy Area East
Check which counties you would be willing to be assigned
IU Health Downtown
St. Vincent 86th
Indy Area Central
Other Counties/areas not list
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