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Power To End Stroke Ambassador Form

Yes, I would like to be an Ambassador for Power To End Stroke. Please complete the form.

*First Name:
*Last Name:
Organization:
*Address:
Address line 2:
*City:
*State:
*Zip:
*Work Phone:
Alternate Phone:
*Email:
 
I can support the Power To End Stroke Movement by (please check all that apply):
Give a Power to End Stroke presentation.
Be a Power to End Stroke spokesperson at an event.
Participate in a Power to End Stroke media interview.
Distribute Power to End Stroke materials.
Promote the Power to End Stroke pledge in the community.
Promote Power to End Stroke to healthcare professionals.
Recruit other individuals to become ambassadors.
Recruit organizations to become involved with Power to End Stroke.
Raising funds to Support Stroke Research.
Join and take actions with our You're the Cure Network, to advocate for stroke research, prevention and elimination of health disparities.
For healthcare professionals, learning and following the American Stroke Association guidelines and displaying Power To End Stroke materials in my office.

For more information contact:
American Heart Association – Midwest Affiliate
Tru-Kechia Smith, Health Equity Director
6800 W. 93rd St.
Overland Park, KS 66212
Phone: (913) 652-1930
Fax: (913) 648-0423
E-mail: Tru-Kechia.Smith@heart.org

Thank you. You have the Power to End Stroke!

For more information on the Power to End Stroke Movement please go to: www.powertoendstroke.org
 
 

 

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