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Congenital Heart Defect Awareness Week
February 7-14, 2010 

An international coalition of families, individuals, non-profit organizations, support groups, and health professionals participate in a campaign to increase public awareness of Congenital Heart Defects and Childhood Heart Disease.

CHD Week Volunteer Proclamations Participants Calendar CHD Lobby Day  

CHD Awareness Week 2010 Healthcare Professional Signup Form

CHD Awareness Week in Dallas, TXIf you would like more information about opportunities to participate in CHD Awareness Week, please tell us about your interests by filling out this form. 

If you or your hospital/practice are already planning CHD Awareness Week activities, please submit this form so that the contact information we have for you is current. We will include your event in our online calendar, and will add the names of the hospitals/practices that you represent to the CHD Awareness Week section of the site. 

If you are NOT a Healthcare Professional, please click here to use the individual/family volunteer form.

C.H.I.N. CHD Week
Healthcare Professional Volunteer Form

Please enter your contact information
(This information will be used only as described above:
please read our privacy statement)
First Name
Last Name
Title
Affiliation
Mailing Address
City
State/Province
Zip or Postal Code
Country
Daytime Phone
Email Address
(enter "None" if none)
(please double-check your address is correct, or we won't be able to contact you via email)

Are you currently planning for CHD Week 2009?
(If not, please skip to the next section)
Please check all that apply Planning an Event 
Local Proclamation Signing
Raising Awareness in the Community
Other:
Has a Date and Location been set for your Event or Proclamation Signing? No
Yes! (Please indicate where and when)
What other hospitals, support groups, and/or organizations are participating?
Do you have corporate or private sponsors for your events? No
Yes! (Please list below)

 Please check here if we can recognize
your sponsors on our site and in our newsletters

Would you like to participate in CHD Awareness Week?
We are interested in participating in CHD Day and would like more information about Planning an event
Publicity
Proclamation Signings
          (state and/or local)
Lapel Pins
Distributing Brochures

Other:

 

Comments and Feedback (Optional)

 
    
 
Please report problems with this form to <sysadmin@tchin.org>
   

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Disclaimer: The contents of this site are presented for informational purposes only, and should not be substituted for professional advice. Always consult your (child's) physicians with your questions and concerns. Created and maintained by Mona Barmash and Uwe Baemayr for The Congenital Heart Information Network. Exempt organization under Section 501(c)3 Copyright ?1996 - 2009 C.H.I.N. all rights reserved TX4-390-685