Name
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First Name
Last Name
Email
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Phone Number
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Which program would you like to be a guest on?
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Please tell us about your role in the congenital heart defect (CHD) or bereaved community (parent, grandparent, heart warrior, doctor, nurse, etc.)
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Please share with us information to help us write your script (this could be CHD information, surgeries, type of loss you’re dealing with (for the bereaved podcast), or any other information that will help us prepare an interesting interview.
If you represent a nonprofit organization, a hospital, or some other entity, please use this box to tell us more information about that.
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This information will be used to write a 150-word bio for you and the questions we will ask you in the interview. Please be concise but give us information to share with our Listeners so they are excited to hear our conversation. Specify what topic you would like to address during the program.
Any other pertinent information?
Heart parents/grandparents-don't forget the names and ages of your other children. Adults with CHDs-let us know how you are now or anything else important in this interview. Professionals-please let us know the hospitals you are affiliated with (or if you prefer not to mention that in the interview), as well as any nonprofit or professional organizations that are important for our Listeners to know about you. Bereaved applicants, is there something else we should know about you or your loved one?
Please click all equipment you have available to use during your recording/interview
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for example Headset with a mic, Earbuds with a mic, Headset with an external mic, WhatsApp, Telephone and/or other equipment.
Please list any and all websites, social media handles, and any other information we should include in the Show Notes for our Listeners to be able to contact you after listening to the program.
Are you interested in volunteering for Hearts Unite the Globe?
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Yes
No
TERMS & CONDITIONS
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