D.C. Pulse

First Name (required) *

Last Name (required) *

Home Address (required) *

Home Address 2

City (required) *

State (required) *

Zip Code (required) *

Cell Phone Number (required) *

- Area Code Phone Number

Work Phone Number

- Area Code Phone Number

E-mail (required) *

Employer (required) *

Position/Title (required) *

Preferred Method of Contact (required) *

Cell Phone Work Phone Email

Business Type (required) *

Corporate Small Business Self-Employed

Please describe any current or past experience with the American Heart Association (required): *

How did you learn about PULSE? (required) *

What connects you to the AHA PULSE D.C. Mission (e.g., family members with heart disease, heart disease prevention, active role in community, company is healthcare focused)? (required) *

Please list any current or past volunteer experience and describe your involvement: (required) *

If you are interested in taking on an active leadership role, please select your preferred areas of focus: check all that apply (required) *

Mission Auction Fundraising Sponsorship Development Event planning New Member Recruitment Social Media/Communications

Please provide some examples on how your involvement with AHA PULSE DC will help support the fundraising and advocacy initiatives of the American Heart/Stroke Association. (Please include suggestions for mission activities and/or fundraising events, specific corporate or personal connections, individual strengths, etc). (required) *

Membership Expectations: (required) *

I am willing and able to invest my time, talent, resources, and contacts to support AHA PULSE DC and its initiatives. I have read and understand the membership expectations, and I would like to be considered.

E-Signature (required) *

Date (required) *

- Month - Day Year