HeartCorps Host Sites Interest Form

HeartCorps Host Sites Interest Form
Center/Organization Name (Required)*
Center/Organization Location (Required)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name (Required)*

First NameLast Name
Title (Required)*
Phone Number (Required)*
Please enter a valid phone number.
Email (Required)*
example@example.com
Website URL
How did you hear about HeartCorps? (Required)*

American Heart Association (local staff)AmeriCorps websiteOnline searchEmployer/professional networkSocial mediaOther
Are you a 501(c)3? (Required)*

YesNo
Number of paid staff: (Required)*
How many people does your center/organization serve annually at this location? (Required)*
How many volunteers engage with your center/organization annually? (Required)*
How many HeartCorps members are you interested in hosting? Please note that you must be able to provide a workspace and onsite management for each member you host. (minimum of 1; maximum of 2) (Required)*
Brief description of your center/organization and mission statement: (Required)*
The impact of the COVID-19 pandemic will continue to be felt in 2023-24, and we want to ensure that program collaborators and potential host sites have contingency plans in place for members. Please provide your organization’s details below, including any requirements for vaccinations.
• What vaccinations are required for anyone to serve onsite at your organization? (Required)*
• Please also share your plans for the role regarding in-person, hybrid, or fully remote service expectations, and any secondary service plans in place if the situation necessitates change. (Required)*
Should be Empty: