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Patient & Caregiver Resources
Survivorship
News & Views
Ways to Donate

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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.

The information published on this website and in our materials is intended to educate you about Oral, Head and Neck Cancer. The content is not intended to take the place of a discussion with a qualified physician who is familiar with your medical situation. It is important to remember that each individual is different, and the reasons for—and outcomes of—any treatment plan depends on the patient's individual condition. If you have questions or concerns after reading any information on this website or in our materials, you should discuss them openly and honestly with your physician. Any products and manufacturers included on this site are presented for informational purposes only and do not constitute product approval or endorsement by HNCA. The content provided by HNCA is in no way intended to be a substitute for medical consultation with a qualified professional. HNCA encourages those using its resources to be careful when evaluating medical information or products. If you are unsure about your medical condition, consult a physician.

HNCA Administrative Office:

1-866-792-4622 (HNCA)

Head and Neck Cancer Alliance PO Box 21688
Charleston, SC 29413

info@headandneck.org

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