EmPOWERED to Serve Community Innovation ExchangeTM
Tell us about yourself.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Please provide a link to your organization’s website.
Tell us about the organization you are submitting to the Community InnovationExchange
*
What is the BIG problem that your organization addresses?
*
Economics/Stability
Education
Environment/Infrastructure
Health/Well-Being
Health Systems
Community/Social Relations
Which cities does the organization focus on supporting?
*
How did you hear about the CIE?
*
heart.org
Empoweredtoserve.org
AHA Staff
Social Media
Search Engine
Other
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
*
Yes
No
An EmPOWERED to Serve team member will contact you after your submission to learn more about your organization.
Submit
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