25-26 Youth Heart Ambassador Application

Youth Heart Ambassador Application

Thank you for your interest in being a Youth Heart Ambassador!
Youth Heart Ambassador Applicant Name*

First Name of ChildLast Name of Child
Age*
Grade entering in September 2025*
What school do you attend?*
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you identify as a survivor?*

YesNo
Video Application

Please upload your video below. In this video, briefly share your story about how you have been affected by heart disease or stroke either through a personal diagnosis, diagnosis of a loved one, or a personal lifestyle change.

Additional instructions:
- Your video should not exceed 2 minutes.
- Parent and child may be together. Story can be shared by either survivor or parent.
Please upload your 1-2 minute video file here.*

Only zip, mp3, mp4, mov, wmp, mpg, flv, avi are allowed. Maximum file size is 180MB.
Cancelof
Is there anything else you want us to know about you/your child?

0/500
Once application has been submitted you will receive an email from RegionAHA.esign@heart.org requesting your signature on an AHA authorization and media release agreement. Your application is complete once we receive that signed document. If you have any questions, please contact YouthAmbassador@heart.org.
Should be Empty:

Youth Heart Ambassador Application