Ambassador Request Form In coordination with our HNCA Chapters, we will work with respective requestors to provide an individual who can offer his/her inspirational story with the insights, challenges, and an overall personal cancer journey narrative. If you are looking to schedule a speaker for an upcoming event, we ask that you provide us with at least a month’s lead time to schedule a speaker for your event. Depending on the location of the event, please know that travel expenses are the responsibility of the requesting company/organization. Organization/Company* Affliation Title Name* First Last Phone*Email* 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 Please check the following requested activities:* Speaker Photo & Interview Video Interview Other List the Other Activities You are RequestingWebsite (optional) Title of EventDate Time : HH MM AM PM Description of EventFlyer or Poster of Event (optional)If you have a flyer or poster with more detail about your event, you can attach it by uploading the file here.Acknowledgment and Agreement* Yes, I agree I hereby acknowledge that it is the requesting company/organization's responsibility to request a speaker from the Head and Neck Cancer Alliance in a month in advance. I hereby understand that the requested speaker is a volunteered position and that I will not hold the Head and Neck Cancer Alliance accountable in providing travel expenses for the speaker for this event and that it is the sole responsibility of the requesting company/organization. 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 HNCA provides me with the information and support I need. It also provides me with a medium to serve as a role model to others diagnosed with head and neck cancer.”Jason MendelsohnStage-4 HPV-related oral 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
HNCA provides me with the information and support I need. It also provides me with a medium to serve as a role model to others diagnosed with head and neck cancer.”Jason MendelsohnStage-4 HPV-related oral cancer survivor
