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Tell Us Your Story

Please fill out this form so that the rescuer can be recognized and the AHA can keep a record of survivor stories and CPR use.  Allow 7 - 10 working days for turnaround. In some cases, awards can be fulfilled more quickly. Please contact heartsaverhero@heart.org with questions or rush requests.

If for any reason this form is unavailable please use this form to submit your story HeartSaver Hero Award.

Many times we receive requests to use survivor stories for AHA marketing purposes, as well as from the media, who may need a story involving someone of a certain gender, race, or age range.

AHA uses this information for future/potential marketing purposes. You will be contacted if we use your story.


* Denotes a required field

Step 1: Rescuer Information  
*First Name
*Last Name
Address
City
State
County
Phone
Email
*Rescuer had AHA CPR training?  Yes          No
Location of CPR Training
Step 2: Shipping Information Address where you would like the Heartsaver Hero Award mailed. We cannot ship to a PO Box.
*First Name
*Last Name
Apartment
*Street
*City
*State
*Zip Code
Step 3: Survivor Information Survivor Info isn’t required but helps ongoing learning about cardiac events.
First Name
Last Name
Age at time of incident
Gender  Female          Male
Ethnicity  African American      Asian      Caucasian      Hispanic      Native American      Other
Type of incident  Sudden Cardiac Arrest      Stroke      Drowning      Choking
Location  Home      Work      School      Other
Brief description of incident
Survivor Contact Information Survivor Info isn’t required but helps ongoing learning about cardiac events.
Street
Apartment
City
State
Zip Code
Phone
Email
Date of Event
AHA Involvement Since the Event
 

 

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