2025 - 2026 Heart Ball Ambassador Application

Name (required):*

First NameLast Name

Phonetic Spelling:

Home Address (required):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email (required):*

example@example.com

Date of Birth:

Date

Ethnicity:

How do you identify (required):*

He/HimShe/HerThey/Them

School Attending & Grade Level (required):*

Sibling(s), Ages & School (required): *

I am interested in being a social media ambassadors for the AHA (required):*

YesNo

Instagram Handle: blanks Twitter: blank TikTok: blank

For the following questions, you may attach additional sheets if needed.

File Upload

What do you hope to gain from your experience as a Heart Ball Ambassador (required)?*

How do you currently exhibit a heart-healthy lifestyle (required)?*

What are your other activities or special interests (required)?*

List three adjectives that your friends would use to describe you (required)?*

How do you demonstrate responsibility towards keeping your commitments(required)?*

What is your personal connection to the American Heart Association? Has anyone in your family or friends had heart disease or stroke? (required)*

Please share any volunteer experience you have (required).*

How did you hear about the Heart Ball Ambassador Program (required)?*

All Ambassadors will receive a t-shirt. T-Shirt Size, please select (required):*

Is there anything else you would like to share, that we have not asked (required)?*

Guardian Information

Parent 1 Name (required)*

Parent 1 First NameParent 1 Last Name

Phonetic Spelling:

Primary Contact*

Yes

Company/Employer (required):*

Home Address (required):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email (required):*

example@example.com

Home Phone (required):

Please enter a valid phone number.

Business Phone:

Please enter a valid phone number.

Cell:

Please enter a valid phone number.

**If parents are separated please include step parent contact info:

Parent 2 Name:

Parent 2 First NameParent 2 Last Name

Phonetic Spelling:

Primary Contact

Yes

Company/Employer:

Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email:

example@example.com

Home Phone:

Please enter a valid phone number.

Business Phone:

Please enter a valid phone number.

Cell:

Please enter a valid phone number.

**If parents are separated please include step parent contact info:

**Billing address: Parent 1blanks or Parent 2 blank (if different).

Parent 1 Signature (required):*

Date (required):*

Date

Parent 2 Signature:

Date:

Date

Ambassador Important Contact Form

The best ways to reach the Ambassador is:

Email (required):*

example@example.com

Text (required):*

Please enter a valid phone number.

Calling my Cell or Home Phone (required): *

Contacting my guardian (required):*

The American Heart Association is allowed to release information about my program participation to the following individuals. (Please list parents, guardians, caregivers and or school professionals.) (required)*

In case of emergency please notify (required):

Contact 1: Name: blanks* Phone number: Phone Number* Email: Email*

Contact 2: Name: blanks Phone number: Phone Number Email: Email

Contact 3: Name: blanks Phone number: Phone Number Email: Email

Financial Contribution:

Level 1

$2,500 - provides entry into the program for 1 ambassador, includes a full table of 10 guests for the night of Heart Ball 2026, priority for interviews and media opportunities.

Level 2

$1,000 - provides entry into the program for 1 ambassador, includes half table of 5 guests for the night of Heart Ball 2026, 2nd priority for interviews and media opportunities.

Level 3

$500 - provides entry into the program for 1 ambassador, includes 2 tickets for the night of Heart Ball

Scholarship

Yes, I am applying for the need based scholarship. No Deposit Required. Includes 2 tickets for the nightof Heart Ball. Ambassador commits to acquiring auction items up to $500.

Payment Options

I prefer to fulfill the total financial obligation at this time.

By Check - made out to the American Heart AssociationBy Credit Card - if you wish to pay by credit card, please contact Carmen Macias at carmen.macias@heart.org

I prefer to pay fees in four installments, with $250 deposit due with application.

By Check - made out the American Heart AssociationBy Credit Card - if you wish to pay by credit card, please contact Carmen Macias at carmen.macias@heart.org

All payments due by Dec. 1st 2025

If choosing installments, select the desired date of the month to run your credit card. (Credit Card will be run monthly, until balance is paid. If needing to delay a payment, let staff know. Total amount is due by January 5, 2026.)

1st15th30th

Required Documents Checklist (required):*

Completed ApplicationLetter of recommendation (attached with application)Signed Code & Mission AgreementRequired Payment: *($100 OR complete payment made with application, if selecting standard payment)

Mail required documents, and appropriate payment to:
American Heart Association
Attn: HB Ambassadors
121 S. Whittier Rd.
Wichita, KS 67207

Email submissions due by July 1, 2025 to Carmen.Macias@Heart.org with subject line "Heart Ball Ambassadors Application"

Heart Ball Ambassador Code & Mission Statement

Ambassadors will focus on all areas of the American Heart Association through service learning, volunteering, advocacy, heart-healthy lifestyles, and discovering how they can individually fight heart disease and stroke. Our goal is to empower these young leaders to make a positive change within their peer groups and in the community by embracing the mission of the American Heart Association.

The American Heart Association stands for good personal health decisions and is against the use of tobaccoproducts by minors. Ambassadors are expected to be free of tobacco when representing the American HeartAssociation at all functions of the Ambassador Program. Also prohibited is the use, sale, or possession of anyillegal drugs.
The 2026 Heart Ball event will provide alcohol to guests who are at or above the legal drinking age, 21 years. It ismy responsibility as an Ambassador and representative of my school, family, and any sponsor to abide by the lawand not consume any alcoholic beverages before, during, or after the Wichita Heart Ball events. It is also myresponsibility to abide by this code and law for any Ambassador activity.

Any Ambassador in violation of any of the above statements will be automatically removed from the Ambassador program without a refund of the monies paid to the American Heart Association.

If chosen to become a Heart Ball Ambassador, I pledge to attend 75% of the Ambassador activities andcommunicate 3 days in advance to local AHA staff when I am unable to attend (exceptions include illness,family emergencies etc.)

As the parent or legal guardian of the child named below (“Child”), I understand, consent and agree that:

In consideration of my Child being allowed to participate in the Heart Ball Ambassador Program (“Program”), my Child and Ihereby expressly assume all risks, including personal injury and fatality, arising in any way out of my Child’s participationand any related activities and services that may be offered as part of the Program.I consent to and permit AHA to take and use video and voice recordings and photographs taken of me or my Child by orprovided by me to the AHA for the purpose of promoting AHA’s mission, its programs and activities (“Images”). “Use” includespublishing such Images for such purpose in any medium, including in social media and may include use of my image andlikeness, my or my Child’s voice only, or excerpts from any interview or presentation. I understand that such Images and thecopyright therein shall be solely owned by AHA, and AHA shall have the right in perpetuity to sell, duplicate, reproduce,adapt, modify, create a derivative work from, and publicly display such Images without any attribution or compensationpaid to me. The rights granted the AHA herein are perpetual and worldwide.

I agree, for myself, my Child, and our heirs, executors and administrators, to not sue and to release, indemnify and hold harmlessAHA, its affiliates, officers, directors, volunteers and employees, from any and all liability, claims, demands, and causes of actionwhatsoever, arising out of my Child’s participation in the Program and related activities, whether it results from the negligence ofany of the above or from any other cause. This Agreement is as broad and inclusive as is permitted by the State in which theProgram is conducted. If any portion of it is held invalid, the balance will continue in full force and effect.

I AM THE PARENT OR LEGAL GUARDIAN OF THE PARTICIPATING CHILD, AND I HEREBY CONSENT TO HIS/HER PARTICIPATIONIN THE PROGRAM, AND RELATED ACTIVITIES. I HAVE READ AND UNDERSTAND THE CONTENT OF THIS RELEASE AND I HAVEEXPLAINED THE CONTENT OF THIS RELEASE TO MY CHILD, AND I HEREBY AGREE TO ALL OF ITS TERMS AND CONDITIONS.

Participant's Signature (required)*

Printed Name (required)*

Date (required)*

Date

I am the legal guardian of Participant, and I hereby consent to their participation. I have read the foregoing release and indemnification agreement, and I hereby agree on behalf of Participant and myself to its terms.

Parent/Guardian's Signature (required)*

Printed Name (required)*

Date (required)*

Date