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American Heart Association - Kentucky 100 Survivors Project
The American Heart Association is nearing its 100th anniversary and to celebrate we want to share 100 of your stories to honor our strong
survivors!
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: https://forms.gle/AkF8xLqHQHnPfXgGA
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* Indicates required question
First and Last Name
*
Your answer
Age
*
Your answer
County of Residence
*
Your answer
Email Address
*
Your answer
Mobile Number
Your answer
Social Media Username
Please indicate platform (Facebook, Instagram, etc.) as well!
Your answer
Are you a heart or stroke survivor?
(Can include conditions that aren't heart attack or cardiac arrest.)
*
Heart
Stroke
Both
When was your initial diagnosis/incident?
(Estimates are fine.)
*
MM
/
DD
/
YYYY
Please share a brief synopsis of your diagnosis and story below.
*
Your answer
Please share something inspiring! (EX: How are you doing post diagnosis/incident? What advice do you have for others? How has your life changed?)
*
Your answer
What AHA initiatives have you previously participated in?
(Please select all that apply.)
*
Heart Walk
Heart Ball
Go Red for Women
Kids Heart Challenge
CycleNation
None
Other:
Required
Are you willing to be interviewed about your story?
*
Yes
No
Please send photo(s) to the email below for social media! (This is a very important step, please don't forget!)
100survivorsproject@gmail.com
*
I did it!
I'll do it later
Where did you hear about the 100 Survivors Project?
*
Social Media
The #LexRedCouch
AHA Staff or Board Member
Website
TV
Radio
Newspaper
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