Contact Information

First Name

Last Name

Phone

Email

Address

City

State
AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingDistrict of Columbia
Zip Code

Social Handles

Personal Information

Date of Birth

Gender
MaleFemale
Ethnicity
American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite
Do you speak more than one language?
YesNo
What languages do you speak?

Highest Level of Completed Education

Interests

What is your connection to aortic disease?
Thoracic Aortic Dissection Survivor - Type AThoracic Aortic Dissection Survivor - Type BLiving with a Thoracic Aortic AneurysmCaregiverMedical ProfessionalLost a spouseLost a parent/grandparentLost a child/grandchildLost a siblingOther
Please give a short summary of your story (400 words or less)

Which target communities would you desire to outreach in? (Select all that apply)
People living with aortic diseaseSomeone who has lost a loved oneMedical ProfessionalsHospitals/professional organizationsLegislators
Are you interested in becoming a lead volunteer within the Aorta Advocate group?
YesNo
Do you have a connection to a hospital?
YesNo
If yes, please describe?

What makes you want to become an aorta advocate?

What skills, qualities or talents do you feel you have that will help fuel our mission?

Have you ever volunteered? (If yes, where and what were a few of your responsibilities?)

Please share any additional information about yourself or your aortic journey you would like us to know.

How did you hear about this program?

By checking this box, you understand that the training to become an Aorta Advocate will happen July 21-24 in Colorado (all fees paid for by The John Ritter Foundation for Aortic Health) is mandatory. If you cannot attend, you will be waitlisted to the 2025 year.

By checking this box, you understand that becoming an Aorta Advocate is a two (2) year commitment.

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