Aktion Health Champions Program Application Form
Form Submission Instructions: Ensure your video is clear and below the specified length before uploading. Double-check all your information for accuracy before submitting. After submission, you should receive an email confirmation.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Current Occupation/Role
*
Country of Residence
*
LinkedIn Profile Link
*
Please provide the URL to your LinkedIn profile to help us understand your professional background.
Highest Level of Education
*
Please Select
High School
Undergraduate Degree
Graduate Degree
PhD
Other
Why do you want to become an Aktion Health Champion?
*
Type a question
*
Website
Social Media
Referral
Other
Introduction Video Upload
*
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Please upload a 2-3 minute video introducing yourself, explaining your interest in mental health, and what you hope to achieve as an Aktion Health Champion.
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