Ambassador Application

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

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.

Ambassador Candidate Form

Recent Posts

Thank You to Our Corporate and Community Partners