2024-2025 Ambassador Application "*" indicates required fields Name* First Last Preferred Name Birth Date* MM slash DD slash YYYY Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Media Handle(s) What is your gender?* Male Female Nonbinary Transgender Another not listed Choose not to disclose What are your pronouns?* He/him She/her They/them Prefer not to answer Ethnicity – multiple choice (select all that apply)* American Indian or Alaska Native People Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer not to answer Are you multilingual?* Yes No If yes, what languages? T-Shirt Size (unisex)* S M L XL XXL XXXL Jacket Size (unisex)* Please upload a photo of yourself to accompany your application. If you’re chosen to be an Ambassador, this is the photo we will use to announce it on social media.*Accepted file types: jpg, png, jpeg, Max. file size: 50 MB. Do you work?* Yes No If yes, where are you employed? What is your job title? How comfortable and interactive with social media are you?* Extremely Comfortable Moderately Comfortable Slightly Comfortable Not at all Comfortable Which social media platform are you most active on?* Facebook Instagram X (formerly Twitter) TikTok LinkedIn Any additional platforms? How comfortable are you with using Zoom, Teams, and other virtual learning tools for interactive meetings and presentations?* Extremely Comfortable Moderately Comfortable Slightly Comfortable Not at all Comfortable How responsive are you to emails?* Extremely Responsive Moderately Responsive Slightly Responsive Not at all Responsive What is your connection to colorectal cancer?* Patient/Survivor Caregiver Family Member of Patient Blood Relative Family Member of Patient NOT Blood Relative Friend of Patient Medical Professional Other In a few sentences, will you share your story with us?* What stage were you/your loved one at the time of diagnosis?* Previvor Rectal – Stage I Rectal – Stage II Rectal – Stage III Rectal – Stage IV Colon – Stage I Colon – Stage II Colon – Stage III Colon – Stage IV N/A Have you/loved one faced any recurrences and/or secondary cancer(s)?* Yes No If yes, please share more. How old were you/your loved one at the time of diagnosis? What was the date of you/your loved one’s diagnosis? MM slash DD slash YYYY If a patient/survivor, are you currently in treatment?YesNoPlease select side effects from the list below that you or your loved one experienced (or currently experience) as a result of treatment and/or surgery. (Please select all that apply) Mouth sores LARS Neuropathy Skin rashes (skin toxicity, chemo rash) Increased anxiety, stress, or mental health issues/illness Other Please describe Did you/loved one get biomarkers (tumor) testing? Yes No Unsure If known, what are your/loved one’s biomarkers? If you/loved one participated in a clinical trial, can you tell us more?If you haven’t participated in a clinical trial, why not? Are you comfortable talking about mental health?* Yes No Do you have any dietary restrictions?* Yes No If yes, please explain your dietary restrictions.Complete this statement. “I fight for...”*Why is it important to you to be a Fight CRC Ambassador?*How did you hear about Fight CRC and the Ambassador Program? Social media Medical Professional Referral Fight CRC website Google Other Please explain Where are you most comfortable sharing your story?* In-Person On Social Media Are you interested in meeting with state or federal policymakers?* Yes No Which Fight CRC initiative(s) excites you the most? Select all that apply.* Advocacy Patient Education Philanthropy / Fundraising Research We ask that all Ambassadors fundraise at least once during their inaugural year. Which opportunity excites you the most? March Awareness Month: Whether you host an in-person fundraising event or create a virtual fundraising page, you directly support Fight CRC’s efforts for the collective good. Climb for a Cure: We’ve raised over $1 million through Climb for a Cure since 2016! Money raised from the Climb directly funds cutting-edge CRC research. End of Year Giving: Create your own fundraising campaign to help us fund our path to a cure for colorectal cancer. Besides colorectal cancer, tell us about a cause you are passionate about.*Are you actively involved with other cancer organizations? Yes No If yes, which organization(s)? Please explain your current involvement.Are you skilled or interested in any of the following?* Writing / Blogging Photography Graphic Design Public Policy Public Speaking Fundraising Patient Education Counseling / Patient Navigation Culinary Arts Event Planning I am not interested in any of the above Please tell us more about the skill or interest you chose above.Would you like to share any other specific skills or connections with us? Are you willing to be active in virtual training sessions throughout the year?* Yes No Our Virtual Kickoff will take place on Tuesday, April 30, 2024, at 6pm CT / 7pm ET. Attendance is mandatory. Are you available?* Yes No Attendance is mandatory for our in-person Ambassador Retreat in Kansas City, Missouri from September 20-23rd, 2024. Ambassadors will cover the cost of their airfare, while Fight CRC will provide lodging, transportation, and meals. Are you available?* Yes No Are you comfortable sharing a room with another Ambassador?* Yes No Are you able to participate in Climb for a Cure this summer? Fight CRC will host the 2024 Climb for a Cure on Saturday, July 20 in the Smoky Mountains.* Yes No If possible, are you willing to be an in-person or virtual participant of our multi-day advocacy event, Call-on Congress in March 2025?* Yes No Are there any issues outside of cancer that may preclude you from traveling or attending any of the Fight CRC events listed above? Is there anything else you’d like us to know about you?CommentsThis field is for validation purposes and should be left unchanged. Δ