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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Profession/Job TitleCurrent EmployerAre you retired? Yes Diagnosis (if you are a patient or survivor)Date of Diagnosis (if you are a patient or survivor)Recurrent?YesNoNot applicableAt 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 InterestsPhotos* Drop files here or A headshot of yourself and other photos/images that convey your personal cancer journey.Personal Story*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. 1-866-792-HNCA (4622) Recent Posts How to Find Your Hope Visiting China: A Glimpse into Life as a Chinese Laryngectomee Genomics Education Workshop with Dr. Terry Day HNCA Board Members Advocate for TEP Patients and Providers Link Between HPV and Head and Neck Cancer If you feel like there is something going on and don’t quite know, Get Screened. Find out what it is. Too many people wait until it’s too late. The key is early diagnosis.Jim KellyNFL Pro Football Hall of Famer and head and neck cancer survivor Thank You to Our Corporate and Community Partners
Recent Posts How to Find Your Hope Visiting China: A Glimpse into Life as a Chinese Laryngectomee Genomics Education Workshop with Dr. Terry Day HNCA Board Members Advocate for TEP Patients and Providers Link Between HPV and Head and Neck Cancer
If you feel like there is something going on and don’t quite know, Get Screened. Find out what it is. Too many people wait until it’s too late. The key is early diagnosis.Jim KellyNFL Pro Football Hall of Famer and head and neck cancer survivor
