Change Champion Application

1

What is your first and last name?* This field is required.

First Name

Last Name

2

Great. Now what's your email?* This field is required.

example@example.com

3

And your phone number?

Please enter a valid phone number.

4

Please copy/paste all your social media handles (e.g. Instagram, Facebook, LinkedIn, Twitter, YouTube, etc.) and website links below.

5

How involved are you on social media when it comes to discussing your condition?

6

What condition communities do you belong to? (i.e. Alzheimer's Disease, Huntington's Disease, IgA Nephropathy, etc.)* This field is required.

7

How frequently do you attend conferences, webinars, or other events related to the condition you advocate for?

Never

Rarely

Occassionally

Frequently

8

Do you currently participate in any support/patient-led groups (e.g. Facebook, Inspire, The Mighty, etc.) or advocacy organizations related to your condition?

YESNO

9

Do you have any experience or interest in the following:

Outreach

Public speaking at events (virtual or in person)

Participating in focus groups or strategy sessions

Creating video content

Blog writing

Podcast interview

10

Do you work with any advocacy groups or platforms? Would you be willing to share your Change Champion experience with those individuals?

YESNO

11

Thank you for applying. We'd love to connect with you!Schedule time with the PicnicHealth team to review your application and discuss next steps.