HeartCorps Host Site Interest Form

HeartCorps Host Site Interest Form

Nonprofits, higher education institutions (including extension services), government agencies, K-12 schools, and tribal councils are eligible for consideration.
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. HeartCorps members typically serve at least 40 hours per week for 10.5 months. (minimum of 1; maximum of 2) (Required)*
Brief description of your center/organization and mission statement: (Required)*
Please note that HeartCorps is a developmental program, aimed to inspire and train individuals as they consider a career in public health. Many of our applicants are early career or are exploring career paths. Our program seeks to improve cardiovascular health outcomes for people living in rural communities through patient education and navigation, community outreach and programming, and implementing policies, systems and environmental changes.
• What other vaccinations are required for members to serve onsite at your organization? (Required)*
• Our most successful efforts to recruit HeartCorps members is often a result of strong collaboration with host sites who activate their existing relationships. What connections or strategies could your organization utilize to help identify viable candidates for placement at your site? (Required)*
The priorities of HeartCorps are blood pressure control, nutrition security, tobacco cessation, and community readiness (CPR). How does your organization envision utilizing a HeartCorps member at your site to address these priorities within your community? Please note: your organization is NOT required to address all four priorities but MUST address at least one. (Required)*
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