Heart Valve Disease Patient Ambassador Program
Heart Valve Voice US (HVV-US) seeks to develop patient advocates who will serve as critical voices on policy and issues affecting valve disease patients!  As an HVV-US Patient Ambassador, you will be able to make a difference on Capitol Hill, in state legislatures, and in your community.  Participation in the program will include learning how to use your voice to educate elected officials and the media about the impact of valve disease and providing input on patient education resources. 
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First and Last Name *
Email *
City  *
State *
Age (please type "N/A" if you prefer not to answer)  *
Please share a brief overview of your journey with heart valve disease. *
What is your connection to heart valve disease? Please select all that apply.  *
Required
What motivates you to become an advocate for heart valve disease? Please select all that apply. *
Required
What advocacy areas are you most interested in? Please select all that apply. *
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Would you be interested in participating in Capitol Hill visits to share your story and speak with policymakers to help influence heart valve disease policy?  *
Are you comfortable sharing your story publicly (e.g., speaking engagements, blog posts, etc.)  *
What types of programming would you be interested in participating in? Please select all that apply.
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Is there anything else you’d like us to know about your interest in becoming an HVV Patient Ambassador? 
Would you like to join the My Valve My Voice community for additional updates and opportunities?  
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How did you hear about the HVV Patient Ambassador Program? 
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