EmPOWERED to Serve Community Innovation ExchangeTM

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
I agree to receive the ETS newsletter ( optional)

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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.
Should be Empty:

An EmPOWERED to Serve team member will contact you after your submission to learn more about your organization.