Kids Heart Challenge / American Heart Challenge Interest Form

1
What best describes your need?* This field is required.
Please Select
Please Select
I wish for my school to participate in KHC/AHC
I am the KHC/AHC Coordinator at my school and need assistance
I am a parent of a participating student and need help
2
Your Name* This field is required.
First Name
Last Name
3
Your Email Address* This field is required.
example@example.com
4
Mobile Phone Number* This field is required.
Please enter a valid phone number.
5
Best Time to Call?
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
AM
PM
Until
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
AM
PM
6
Contact Preference
Email
Phone
Text
7
What questions or needs do you have? How can we help?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
8
Tell us more about the type of event you would like to start and how we can help:
Huge
Large
Normal
Small
Ok
Ok
9
School Name* This field is required.
10
School City* This field is required.
11
School State* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Should be Empty: