Sick Cells' Ambassador Program Interest Form

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To express your interest in becoming a Sick Cells Ambassador, please fill out the form below.

More information about the Ambassador Program can be found on our website: https://www.sickcells.org/ambassador-program

Questions? Email Kelly at khawthorne@sickcells.org.

First Name *

Last Name *

Preferred pronouns

She/Her

He/Him

They/Them

Other:

Clear selection

Email Address *

Street Address

City

State

Zip Code

Phone number (best number to reach you)

What is your relationship to sickle cell disease? *

How long have you been involved as an advocate for the sickle cell disease community? *

0-2 years

3-5 years

6-10 years

11-20 years

20+ years

Do you currently work with any other sickle cell organizations? List up to 3 affiliations.

Which areas of advocacy do you have experience in? Select all that apply. *

Awareness and educational campaigns

Clinical research and/or drug development

Federal policy and legislation

State or local policy and legislation

Safety and clinical practice guidelines

Patient assistance programs or direct services

Community or coalition building

Health insurance coverage

Hospital or clinic-based advocacy

Advocacy within governmental agencies (FDA, HRSA, etc.)

Other:

Required

Please provide between 5-8 sentences about your experiences advocating for sickle cell disease, reflecting on your answers provided above. (In your response, please discuss activities you've been involved in as an advocate, or would like to get involved in. Please also provide one sentence about what motivated you to become involved with this Ambassador Program). *

Would you be interested in submitting your personal story to our Faces of SCD Campaign?

Yes

Clear selection

Which populations or communities do you work with or represent? Select all that apply. *

Racial/ethnic minorities

Immigrant groups

Children

LGBTQ+

Low income

Low health literacy

Rural

Urban

Virtual communities (social media networks, forums, online chat rooms, etc).

None

Other:

Required

Where do you currently live? *

Please share your social media handles.

Consent to Share this Information

By clicking Submit, you understand and agree that Sick Cells may process and use the personal information you have submitted in this survey for purposes of carrying out the Sick Cells Ambassadors Program. You are consenting to participate in the program, and for your personal information to be stored in Sick Cells' secure database.

(Ambassadors are always able to leave the program at any time and their data will be removed from the database.)

Submit

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