Ambassador Application

Ambassador Candidate Form

Being a speaker is a voluntary role. All new speakers work with the HNCA Communications Director to optimize presentation skills and organize their thoughts. Once approved as a speaker, you will be contacted to share your journey at community events, with researchers and/or fundraising functions.

Name*
First Last
I am a (check all that apply):*
- Patient
- Survivor
- Caregiver (Family Member)
- Caregiver (Friend)
- Other
How are you related to the patient for whom you provide care?
If you chose Other, please tell us why are you interested in being an Ambassador.
Email*
Phone*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Profession/Job Title
Current Employer
Are you retired?
- Yes
Diagnosis (if you are a patient or survivor)
Date of Diagnosis (if you are a patient or survivor)
Recurrent?
- Yes
- No
- Not applicable
At what hospital or medical facility were you treated?
Please check the following interest(s)*
- Speaking
- Photo & Interview
- Video Interview
- Blogging
- Patient Network Activities
- Research Studies/Clinical Trials
- Other
List Other Interests
Photos*
Drop files here or

Max. file size: 100 MB.
A headshot of yourself and other photos/images that convey your personal cancer journey.
Personal Story*
Max. file size: 100 MB.
6-10 paragraphs of your personal journey (details of family life, age of diagnosis, type of cancer, treatment, years as a cancer survivor and other pertinent details of your cancer journey. Please attach your journey in a word doc. or pdf format.
Acknowledgment and Agreement*
- Yes, I agree
I hereby acknowledge that this position is a voluntary role and have no expectation to receive any monetary compensation or reimbursement. I hereby agree to give my consent to share my personal cancer story, along with images/videos submitted, as a speaker for public events, media and/or materials in relation to the Head and Neck Cancer Alliance.

Ambassador Candidate Form

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