EmPOWERED to Serve Community Innovation Exchange ™
Tell us about your self.
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
The Project You are Submitting to the Community Innovation Exchange
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What is the BIG problem that your project addresses?
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Economics/Stability
Education
Environment/Infrastructure
Health/Wellbeing
Health Systems
Community/Social Relations
What are the cities where this project is focused on supporting?
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In your own words, how wide does your location /mission reach?
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(Example, we reach a 15 mi. radius, our mission effects people within 3 blocks, we work in the entire DMV area)
What is the size of your organization?
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0-10 Employees
11-50Employees
51-200Employees
200+ Employees
What do you need to make this project successful ?
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Section1: Tell Us Your Project.
What were the conditions in your community that led to the start of this?
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Why is Your Organization Leading this Project?
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(i.e., the journey, history, etc.)
How does this project improve the health of the community?
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(include data/statistics, etc.)
What type of challenges did you face when activating this project?
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What is the best scenario for how this project evolves?
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Why are you committed to seeing this project through to its completion?
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JUST ASK: As you’re working this project, what do you need to make this project successful?
Section 2 : Case Studies, Testimonials and Impact
Submit Any White Papers, PowerPoint Slides, etc
Browse Files
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of
Submit banner for the website. Requirements :1190 x 500 high resolution
*
Browse Files
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Submit photograph to be used on the abstract
Browse Files
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Testimonials
Video Links
Please share your social media platform URL's and followers.
(example https://www.facebook.com/EmPoweredToServe/ 1000followers)
Media acknowledgements/press (blogs)
Alliances /collaborations
Company Website- enter a valid website URL
for example http://www.google.com
Section3: Demographics and Background Data
Does your organization have volunteer opportunities?
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Yes
No
Please share the volunteer opportunities.
Have you worked in any capacity with the American Heart Association (AHA) and/or received prior funding from the AHA? If so, please describe
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Does your business have any of the certifications below (check all that apply) ?
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MBE– Minority Owned Business
WBE– Women Owned Business
DBE– Disadvantaged Business Enterprise
HUBZone
VOSB- Veteran-Owned Small Business
SDVOSB– Service-Disabled Veteran-Owned Small Business
Does your concept/submission have a patent?
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Yes
No
Is your patent currently being challenged or are you in current litigation with other organizations or entities?
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Yes
No
How did you hear about the CIE?
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heart.org
Empoweredtoserve.org
AHA Staff
Social Media
Search Engine
I agree to receive the ETS newsletter ( optional)
Yes
No
I certify that I am authorized to release this information to the American Heart Association and agree that any information provided to the AHA, whether as part of this intake form or otherwise, may be disclosed by the AHA and that I have sufficient rights, whether by implication, estoppel, or otherwise, to grant AHA the rights discussed in this form
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Yes
No
Submit
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