Kansas - Share your Story

Name

First NameLast Name

I am a:

SurvivorParent or family member of a survivorAdvocate

Survivor's Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address:

example@example.com

Phone Number:

Area CodePhone Number

The best way to reach me is:

Age

Ethnicity

Have you ever shared your story before, if so when and where?

Are you interested in sharing your story as a spokesperson for the American Heart Association?

YesNo

Media requests often happen on short notice, please list your availability/flexibility.

Overview of your story.
(Somethings to consider: what's your heart condition, or stroke story; were you born with it or did it develop; are you still receiving treatment; how did this experience change your life, etc.)

What do you want people to know about the American Heart Association and why it's important to participate, be it through the Kids Heart Challenge, at local events or in your community?

Please know the American Heart Association is grateful to people like you for sharing your story. We work hard each day to find cures, treatments, and change public policy and behaviors. Your stories make it possible.

Upload photos (optional)

Browse Files

I have read the Release and Copyright Transfer Agreement above and by checking this box I agree to the terms and give consent.*

Yes