Heart to Heart with Anna Guest Survey

Guest Survey

Please answer the following questions to help us get to know you better and to help us match you to a future episode of Heart to Heart with Anna: A Show for the Congenital Heart Defect Community.

Question Title

* 1. Please share the contact information you would like for us to use:

Name

Preferred Email Address:

Alternate Email Address:

Home Phone (please include area code and country code if outside the USA):

Mobile Phone (please include area code and country code if outside the USA):

Work Phone (please include area code and country code if outside the USA):

Facebook Name:

Twitter Handle:

Skype Name:

Question Title

* 2. Please tell me about your role in the congenital heart defect community is

I am a Heart Warrior

N/A

I am a Heart Parent

N/A

I am related to a person with a heart defect

N/A

I work in the medical field dealing with congenital heart defects

N/A

I work with a nonprofit organization that helps the congenital heart defect community

N/A

Other

N/A

Question Title

* 3. Please indicate what topics you would like to address (only answer those which apply to your interests):

Topic for Season 10: Education for Heart Warriors

Topic for Season 11: Heart Warrior Siblings

Topic for Season 12: Organ Donation and Transplantation

Topic for Season 13: Authors and Musicians in the CHD Community

Topic for Season 14: CHD Community Members Working in the Medical Field

Topic for Season 15: The Psychology of Living with a CHD

Question Title

* 4. Please indicate why you would be the perfect Guest for this Season:

Topic for Season 10: Education for Heart Warriors

Topic for Season 11: Heart Warrior Siblings

Topic for Season 12: Organ Donation and Transplantation

Topic for Season 13: Authors and Musicians in the CHD Community

Topic for Season 14: CHD Community Members Working in the Medical Field

Topic for Season 15: The Psychology of Living with a CHD

Question Title

* 5. Indicate the 3 best times you are available (please indicate day, time and time zone)

Best Time:

2nd Best Time:

3rd Best Time

Question Title

* 1. Please share the contact information you would like for us to use:

Question Title

* 2. Please tell me about your role in the congenital heart defect community is

Question Title

* 3. Please indicate what topics you would like to address (only answer those which apply to your interests):

Question Title

* 4. Please indicate why you would be the perfect Guest for this Season:

Question Title

* 5. Indicate the 3 best times you are available (please indicate day, time and time zone)

Question Title

* 6. Is there anything else we should know about you?