2026 Jackson Teen of Impact Application
Please submit this completed form by October 18th
Nominee Information
Name
*
First Name
Last Name
Age
*
Grade & School (example: 6th - Jackson Public School)
*
Email
*
example@example.com
Application Questions
1. Tell us about yourself (your interests, hobbies, school activities, and what makes you unique).
*
2. Why do you want to be a Teen of Impact?
*
3. How have you shown leadership or made a positive difference for others? This could include volunteering, fundraising, mentoring, advocacy, or everyday kindness.
4. Do you have a personal connection to heart disease or stroke?
*
Yes
No
4a. If yes, please share.
5. What strengths or passions would help you succeed in this campaign, and how would you inspire others to support the American Heart Association?
*
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Email
*
example@example.com
Agreement
Nominee Signature
*
Date
*
-
Month
-
Day
Year
Date
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: