Sick Cells' Ambassador Program Interest Form
To become a Sick Cells Ambassador, please fill out the interest form below.

More information about the Ambassador Program, including our Code of Conduct, can be found on our website: https://www.sickcells.org/ambassadors-program

Questions? Email Elodie at eontala@sickcells.org.
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First Name *
Last Name *
Preferred pronouns
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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? *
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. *
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?
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Which populations or communities do you work with or represent? Select all that apply. *
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.)
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