Histiocytosis Association

Thank you for your interest in the Histio Youth Ambassador Program! The following questions serve as your application as a Youth Histio Ambassador with the Histiocytosis Association. The application is open throughout the year and takes about 15 minutes to complete. If you are under the age of 18, please ask a parent/legal guardian to help you fill out the application. Once your application has been reviewed, a representative from the Histiocytosis Association will contact you for an interview with you and your parent/guardian. 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!

Please provide an address so we can send you materials and goodies!

Your Contact Information:


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province: Required
*	ZIP / Postal Code: Required
*	Country: Required
*	Phone Number: Required
	Yes, I'd like to receive email updates from the Histiocytosis Association.

Parent/Guardian Contact Information

*

Question - Required - Full Name:

*

Question - Required - Email:

*

Question - Required - Is the Parent/Gaurdians Address the same as the youth applicant's?

If the parent/guardian address is different from the youth applicant please provide below:

Question - Not Required - Mailing Address Line 1

Question - Not Required - Mailing Address Line 2

Question - Not Required - City:

Question - Not Required - State/Province:

Question - Not Required - Zip/Postal Code:

Question - Not Required - Country:

*

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

Histiocytosis Information:

*

Your Relationship to Patient:

(Select one of the available choices or enter a different value.)
Question - Required -

*

Question - Required - Are you a bereaved family member?

*

Question - Required - Age of diagnosis / age of patients you treat

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

Day

Year

*

Question - Required - Please list any skills/talents that you possess that will help you serve the Histio Community as an Ambassador (ie writing, drawing, digital media design, public speaking, language translation, youth sports, singing, acting, can play an instrument, photography, arts and crafts):

*

Question - Required - *Please list any other organizations that you belong to (ie scouts, athletic clubs, service organizations, school clubs)

(Maximum response 255 chars, approx. 5 rows of text)

*

Question - Required - Do you fluently read/speak/write a language other than English?

Question - Not Required - If yes, which language(s):

*

Question - Required - Have you participated in a Histiocytosis Association event in the past?

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
	Community Outreach Events
	Fundraising
	Public Presentations
	Research
	Social Media/Virtual Networking

*

Question - Required - How many approximate hours per month do you feel comfortable contributing to the Histio Youth Ambassador Program?

*

Question - Required - Briefly, please tell us about your interest in volunteering as a Histio Youth Ambassador:

Question - Not Required - Is there anything else you would like us to know about you?

Histio Youth Ambassador Application

Histiocytosis Association, Inc.

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