Ambassador Interest Form

We would like to get to know you before training! What is your availability for a phone call?*

Which histiocytic disorder(s) have directly affected your life? Healthcare Providers, please select any histiocytic disorder(s) you have experience with:

Your Relationship to Patient:*

Age of diagnosis / age of patients you treat*

Which histiocytic disorder(s) have directly affected your life?*

Are you a bereaved family member?*

Your Date of Birth:*

Do you have experience with any of the following? (Check all that apply)*

Please list any skills/talents that you possess that will help you serve the Histio Community as an Ambassador (for example: graphic design, public speaking, language translation, coaching, active listening, etc.):*

Which areas of ambassadorship are you most interested in? (check all that apply)*

Advocacy Education/Awareness Face to Face Community Outreach Events Fundraising Public Presentations Research Social Media/Virtual Networking Social/Emotional Support

Do you fluently read/speak/write a language other than English?*

If yes, which language(s):

Have you participated in a Histiocytosis Association event in the past?*

If yes, please list the event(s):

Briefly describe your interest in volunteering:*

Approximate hours per month you can contribute:*

Anything else you would like us to know?

Volunteer / Ambassador Interest Form

Contact Information

Address

Let’s Get Started!

Histiocytosis Association, Inc.

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