Heart to Heart Ambassador Application

Thank you for your interest in becoming an ACHA Heart to Heart Peer Mentor. Please make sure to carefully review the "Peer Mentor Roles and Responsibilities" section listed here before applying.

If you have questions, please contact ACHA's Peer Mentor Coordinator Karla Deal at kdeal@achaheart.org.

Relationship with CHD

Applicant Info

First and Last Name *

Address *

Address 2

City *

ZIP/Postal Code *

Home Phone

Cell Phone

Email Address *

Confirm Email Address *

Date of Birth *

Your Current Occupation and Employer *

What is your first language? *

Short Answer Questions

How did you learn about the Peer Mentor Program? *

What unique qualities, skills or experiences can you offer to the Peer Mentor Program? *

What would you like to gain from becoming a Peer Mentor?

What do you think will be your biggest challenge should you become a Peer Mentor? *

What would you like to offer the Heart to Heart (H2H) Peer Support Program? *

What do you think other CHD patients (and/or family members) would gain if you were their Peer Mentor? *

Please share any additional relevant work or volunteer experience.

Please share anything else you’d like us to know about you.

Letters of Reference

Please read these instructions for sending letters of recommendation carefully, as it is the applicant’s responsibility to ensure all letters are submitted as outlined below:

For Patients: You must submit one statement from an ACHD healthcare professional. Your ACHD healthcare professional should confirm that you are compliant and understand the need for lifelong ACHD care. One letter of reference should be from someone who knows you professionally, such as an employer, teacher, or volunteer coordinator. One letter of reference should be from someone who knows you personally, such as a friend, neighbor, or co-worker.

For Family Members and Loved Ones: Please submit three letters of reference. One must be from someone who knows you professionally, such as an employer, teacher, or volunteer coordinator.

*All letters should address the following areas: commitment, reliability, accomplishments, strengths, experience in dealing with people, how you handle challenges, and why they believe you are a good example of someone who thrives with CHD.

All professional letters should be submitted on letterhead and have a signature. Letters should be emailed as attachments to kdeal@achaheart.org or faxed to 215-849-1261. You may email ACHA's Peer Mentor Coordinator Karla Deal at kdeal@achaheart.org regarding the receipt of your letters of reference.

Letter of Reference 1 - ACHD Provider or Professional Reference

Name (Reference 1) *

ACHD Program *

Address (Reference 1) *

Telephone Number (Reference 1) *

Email address (Reference 1)

Letter of Reference 2 - Professional Reference

Name (Reference 2) *

Business or Institution Name (Reference 2) *

Address (Reference 2) *

Telephone number (Reference 2) *

Email Address (Reference 2)

Letter 3 - Professional or Character Reference (Non-Family Member)

Name (Reference 3) *

Business or Institution Name (Reference 3) *

Address (Reference 3) *

Telephone Number (Reference 3) *

E-mail Address (Reference 3)

Signature

I have received and read ACHA's Heart to Heart Peer Mentor description.

Please read the following carefully prior to signing and submitting your application. I understand that by signing this form, I acknowledge the following limitations of the role of a Peer Mentor:

• I am not a therapeutic counselor.

• I am not allowed to provide medical advice.

• I should not be the sole support system of a member I am matched with while a part of the program.

By signing this form, I further acknowledge the following:

*I have read and understand the Peer Mentor description as outlined above. * I understand that as a patient or a family member/loved one of someone affected by CHD, limited confidential medical information (including, but not limited to name, age, diagnosis) pertaining to me may be released to ACHA staff and that this information will be kept in the strictest confidence by ACHA staff. * Selection of Peer Mentors is based on the needs of the program (including, but not limited to geographic location and type of defect) and that by applying to the program, I am not guaranteed a spot within the program. * My application will only be considered if all three letters of recommendation are received by March 31, 2023. I may contact ACHA's Peer Mentor Coordinator Karla Deal at any time to follow up on receipt of my letters by emailing kdeal@achaheart.org.

I have received and read ACHA's Heart to Heart Peer Mentor description. *

3/22/2023

ACHA Heart to Heart Peer Mentor Application

Thank you for your interest in becoming an ACHA Heart to Heart Peer Mentor. Please make sure to carefully review the "Peer Mentor Roles and Responsibilities" section listed here before applying.

If you have questions, please contact ACHA's Peer Mentor Coordinator Karla Deal at kdeal@achaheart.org.

I have received and read ACHA's Heart to Heart Peer Mentor description.