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The required items are marked with

Parent Member – Those that have lost a child to sudden cardiac arrest.

Associate Member – Survivors of SCA, those living with heart issues or that have children living with heart issues.

Partner – Other individuals, organizations or businesses who want to participate in the mission of preventing SCA in kids.

First Name:

Last Name:

Spouses Name:

Address:

City:

State:

Zip:

Phone #:

E-Mail:

Website:

Share your story:

If you have lost a child:

Child's First Name:

Child's Last Name:

Child's Date of Birth:

Child's Date of Death:

Do you have a child that has been diagnosed with a heart condition?

Child's First Name:

Child's Last Name:

Child's Date of Birth:

Have you been told that you or other family members should be tested for an arrhythmia?

Have you formed or been a part of any other heart organizations?
If yes, please describe the organization.

What are your areas of interest?	SCA Advocacy Efforts
	SCA Education Efforts
	SCA Research Efforts
	AED Placement
	Cardiac Screenings

Have you placed any defibrillators in public places? If yes, now many?

Are you an AED/CPR Instructor? If yes, how many people have you trained?

Have you hosted heart screenings? If yes, how many people have you screened?

Other Comments: