Heart Club Registration Form

Heart Club Registration Form
- This application will take about ten minutes to complete.
- You must complete this application to become an active Heart Club.
- To start a Heart Club you must secure a faculty/staff advisor from your school. Confirm your advisor and collect their email address and contact number before you start this application.
- All Heart Club members must be 13 or older.
- Section 5 of this application requires you to submit a consent form. If under 18, a parental signature is required.
- Once your application is reviewed by our team, you will receive an email with next steps (within 7-10 business days).
- High schools and universities located in the United States and U.S. territories are eligible to register a Heart Club. At this time, we cannot accept applications from schools outside of these geographic regions.
- If you have any questions, please email: HeartClub@heart.org
Section 1: Personal Information
Student First Name and Last Name *

Student First NameStudent Last Name
Email Address: *
example@example.com
Phone Number:*
Please enter a valid phone number.
Grade Level for the 2024-2025 school year: *

Section 2: School Information
School Type: *
School Name*
School Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Section 3: Questionnaire
How did you find out about Heart Club?*
Which American Heart Association initiative have you participated in before? Select all that apply. *
Does your High School or College Participate in an American Heart Association fundraiser?Select all that apply. *
Are you a heart disease or stroke survivor?*
If yes, are you interested in sharing your personal story? *

Section 4: Advisor Information
Advisor First Name & Last Name:*

Advisor First NameAdvisor Last Name
Job Title:*
Email Address:*
example@example.com
Preferred Phone Number:*

OfficeHomeCell
Office Phone Number: *
Please enter a valid phone number.
Home Phone Number: *
Please enter a valid phone number.
Cell Phone Number: *
Please enter a valid phone number.

Section 5: Consent Form
Name of Student:*

Student First NameStudent Last Name
School Attending:*
Grade in School: *
Student’s Birthdate:*

MonthDayYear
Date
Current date:

MonthDayYear
Date
Age
Email:*
example@example.com
Telephone Number:*
Please enter a valid phone number.
Emergency Contact Name: *

Emergency Contact First NameEmergency Contact Last Name
Relation to the Student: *
Work Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Cell Phone:*
Please enter a valid phone number.
Consent, Release, and Indemnification

Thank you for participating or allowing your child to participate in the American Heart Association, Inc.’s (“AHA”) youth volunteer initiative, HEART CLUB, which supports the mission of the American Heart Association to be a relentless force for a world of longer, healthier lives. This commitment and participation will include online training, service projects that may include posting online, teleconferences and completing online surveys about volunteer experiences. I hereby expressly assume all risks, including personal injury and death, arising in any way out of my participation or my child’s participation in HEART CLUB and any related activities and services offered through Heart Club in which I or my child voluntarily participates.

I understand and agree that:

I am, or my child is, able to participate in all related activities and services. My Child or I can choose to stop participating at any time.

I agree, for myself or my child, my heirs, executors and administrators, to not sue and to release, indemnify and hold harmless, the American Heart Association, Inc., its affiliates, officers, directors, volunteers and employees, and all sponsoring businesses and organizations and their agents and employees (collectively “AHA”), from any and all liability, claims, demands and causes of action whatsoever, arising directly or indirectly out of my participation, or my child’s participation, in this event and related activities and services — whether it results from the negligence of any of the above or from any other cause.

I authorize the use, copyright, or publication of my or my child’s name, image or voice from participating in the Event and related activities, as may be captured by photograph or recording in any medium for any purpose, including illustration, promotion, or advertisement. As a condition of participation, I grant AHA a perpetual, irrevocable, worldwide, transferable, royalty-free, and non-exclusive license to use, reproduce, adapt, modify, publish, distribute, publicly perform, create a derivative work from, and publicly display this activity, including display on the AHA website, without any attribution or compensation.

I agree that AHA may use and share personal information about me or my child that I give AHA, that I may have given to AHA previously, that AHA collects through its websites, apps, social media sites, devices, as well as the information about me that AHA combines with that collected by others.

AHA uses and shares my personal information to fulfill AHA’s mission to be a relentless force for a world of longer, healthier lives, to notify me of donor opportunities and offer me products and services, to provide me with products or services that I request, and to improve AHA’s programs and websites.
I can learn more about how AHA uses, shares, and protects my personal information by reading the AHA Privacy Policy.

I hereby (i) consent to the American Heart Association contacting me or my child using the email address or telephone number provided above about HEART CLUB and (ii) give my permission for my child or myself to participate in HEART CLUB.

If I am registering a child under the age of 18 or an incapacitated adult I represent and warrant that I am the parent or legal guardian of that party and have the legal authority to enter into this agreement on their behalf and by proceeding with this event registration.

This agreement is meant to be as broad and inclusive as permitted by the State or Province in which the event is conducted. If any portion of it is invalid, the balance will continue in full force and effect.
Printed Name of Student:*
Signature of Student:*

Clear
Date*

MonthDayYear
Date
If under 18, parental signature is required.
Printed Name of Parent/Guardian:*
Signature of Parent/Guardian:*

Clear
Date*

MonthDayYear
Date

Section 6: Confirm and Submit
Please check the box below to confirm the acknowledgement*

By checking this box, I declare the information provided is true, correct and complete, and I have read and fully understand the Ethics Policy and Privacy Policy and intend to be bound by its terms.
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