Request an Ambassador - Head and Neck Cancer Alliance

Ambassador Request Form

In coordination with our HNCA Chapters, we will work with respective requestors to provide an individual who can offer his/her inspirational story with the insights, challenges, and an overall personal cancer journey narrative. If you are looking to schedule a speaker for an upcoming event, we ask that you provide us with at least a month’s lead time to schedule a speaker for your event. Depending on the location of the event, please know that travel expenses are the responsibility of the requesting company/organization.

Organization/Company*
Affliation Title
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Please check the following requested activities:*
- Speaker
- Photo & Interview
- Video Interview
- Other
List the Other Activities You are Requesting
Website (optional)
Title of Event
Date
MM slash DD slash YYYY
Time

: Hours

Minutes

AM/PM
Description of Event
Flyer or Poster of Event (optional)
Max. file size: 2 GB.
If you have a flyer or poster with more detail about your event, you can attach it by uploading the file here.
Acknowledgment and Agreement*
- Yes, I agree
I hereby acknowledge that it is the requesting company/organization's responsibility to request a speaker from the Head and Neck Cancer Alliance in a month in advance. I hereby understand that the requested speaker is a volunteered position and that I will not hold the Head and Neck Cancer Alliance accountable in providing travel expenses for the speaker for this event and that it is the sole responsibility of the requesting company/organization.