Ambassador Application

Name*

First Last

I am a (check all that apply):*

Patient
Survivor
Caregiver
Other

Email*

Phone*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Profession/Job Title

Current Employer

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

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 as a speaker for public events, media and/or materials in relation to the Head and Neck Cancer Alliance.

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Ambassador Candidate Form

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