Histio Ambassador Application Thank you for your interest in the Histio Ambassador Program! The following questions serve as your application as a Histio Ambassador with the Histiocytosis Association. You will receive a response from a member of our team within 72-hours of submitting your application. Thank you again for your time and consideration. Let's Get Started! Your Contact Information: * First Name: Required * Last Name: Required * Email: Required * Phone Number: Required Yes, I'd like to receive email updates from the Histiocytosis Association. * Question - Required - We would like to get to know you before training! What is your availability for a phone call? Please select response Morning Afternoon After 5pm Please provide an address so we can send you materials and goodies! * Question - Required - Mailing Address: Question - Not Required - Mailing Address Line 2: * Question - Required - City: * Question - Required - State/Province: * Question - Required - Zip/Postal Code: * Question - Required - Country: Histiocytosis Information: * Question - Required - Which histiocytic disorder(s) have directly affected your life? Healthcare Providers, please select any histiocytic disorder(s) you have experience with: Please make at least 1 selection from the choices below. Diabetes Insipidus (DI) Erdheim-Chester Disease (ECD) Hemophagocytic lymphohistiocytosis (HLH) Histiocytic Sarcoma Langerhans Cell histiocytosis (LCH) Pulmonary Langerhans Cell histiocytosis (PLCH) Rosai-Dorfman Disease (RDD) Xanthogranuloma (JXG/XG) Other histiocytic disorder or related condition * Question - Required - Your Relationship to Patient: Please select response Self Parent Sibling Spouse Grandparent Other Family Member (Aunt/Uncle/Cousin/etc.) Friend Physician Nurse/Other Healthcare Professional Social Worker/Child Life Specialist * Question - Required - Are you a bereaved family member? Please select response Yes No * Question - Required - Age of diagnosis / age of patients you treat Please select response Pediatric Adult Question - Not Required - Do you have experience with any of the following? (Check all that apply) Adult Hospital Stays Chemotherapy Clinical Trials Central Nervous System Involvement Genetic Testing (i.e.; B-RAF, PRF1, STX11, etc.) Immunotherapy Long Term Effects Monitoring Only Pediatric Hospital Stays Radiation Steroids Surgical Removal of Disease Transplantation Tell us a little more about yourself! Question - Not Required - Your Date of Birth (optional): Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2040 2039 2038 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 * Question - Required - 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.): * Question - Required - Do you fluently read/speak/write a language other than English? Please select response Yes No Question - Not Required - If yes, which language(s): * Question - Required - Have you participated in a Histiocytosis Association event in the past? Please select response Yes No Question - Not Required - If yes, please list the event(s): * Question - Required - Which areas of ambassadorship are you most interested in? (check all that apply) Please make at least 1 selection from the choices below. Advocacy Education/Awareness Face to Face Community Outreach Events Fundraising Public Presentations Research Social/Emotional Support Social Media/Virtual Networking * Question - Required - How many approximate hours per month do you feel comfortable contributing to the Histio Ambassador Program? Please select response 1-2 hours 3-5 hours 6-8 hours 8+ hours * Question - Required - Briefly, please tell us about your interest in volunteering as a Histio Ambassador: Question - Not Required - Is there anything else you would like us to know about you? wdewx * Name: First Required Last Required * Email: Required Please check this box to receive or continue receiving periodic email updates from Histiocytosis Association Yes, I would like to receive postal mail from Histiocytosis Association Spam Control Text: Please leave this field empty
