Share Your Story
Name & Contact Information
Your relationship to the Heart Warrior
Please select...
I am the Heart Warrior
Parent
Caregiver/Guardian
Grandparent
Sibling
Healthcare Professional
Other
If other, please specify.
First Name
Last Name
Preferred Name
Date of Birth
Gender
Please select...
Female
Male
Transfeminine
Transmasculine
Non-binary
Gender-nonconforming
Prefer not to answer
Other
If other, please specify.
Pronouns
she/her
he/him
they/them
prefer not to say
other
If other, please specify.
Race/Ethnicity
Select all that apply:
American Indian or Alaskan Native
Asian or Asian American
Black or African American
Hispanic or Latino/a/x
Native Hawaiian or Other Pacific Islander
White or Caucasian
Prefer not to answer
Other
If other, please specify.
Street Address
Street Address 2 (Unit, Apt, etc. or NA)
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Email
Phone Number
Your Heart Warrior
First Name
Last Name
Preferred Name
Date of Birth
Please select their current age group:
Infant (birth to 23 months)
Preschooler (2-5)
School age (6-12)
Teen (13-17)
Young adult (18-39)
Adult (40+)
Please select their age at diagnosis:
Prenatally
Infant (1 and under)
Preschooler (2-5)
School age (6-12)
Teen (13-17)
Young adult (18-39)
Adult (40+)
Gender
Please select...
Female
Male
Transfeminine
Transmasculine
Non-binary
Gender-nonconforming
Prefer not to answer
Other
If other, please specify.
Pronouns
she/her
he/him
they/them
other
prefer not to say
If other, please specify.
Race/Ethnicity
Select all that apply:
American Indian or Alaskan Native
Asian or Asian American
Black or African American
Hispanic or Latino/a/x
Native Hawaiian or Other Pacific Islander
White or Caucasian
Prefer not to answer
Other
If other, please specify.
Type of heart condition/s
Single Ventricle Heart Defect
Two Ventricle Heart Defect
Transplant
Acquired Heart Condition
Cardiomyopathy
Pediatric Pulmonary Hypertension
Vascular Rings/Slings/Tracheal Rings
Arryhthmia(s)
Other
If other, please specify.
Please specify the exact diagnosis/es.
Do they have any additional diagnoses?
Genetic
Mental Health
Other
None
If other, please specify.
Please specify the exact diagnosis/es.
Primary Hospital for Cardiac Care
Please select...
Boston Children's (Boston, MA)
Children's Healthcare of Atlanta (Atlanta, GA)
Children's Hospital of Colorado (Denver, CO)
Children's Hospital of Philadelphia (Philadelphia, PA)
Children's Mercy Hospital (Kansas City, MO)
CPCMG/Children's Primary Care Medical Group (San Diago, CA)
Lucile Packard Children's Hospital (Palo Alto, CA)
Lurie Children's Hospital (Chicago, IL)
Mercy Children's Hospital (St. Louis, MO)
Rady Children's Hospital (San Diego, CA)
Seattle Children's Hospital (Seattle, WA)
SSM Cardinal Glennon Children's Hospital (St. Louis, MO)
St. Louis Children's Hospital (St. Louis, MO)
UH Rainbow Babies & Children's Hospital (Cleveland, OH)
Other (specify below)
If other, please specify.
Your Story
Storytelling is powerful and it is YOUR story to tell in as much detail as you want. Sharing your story helps others feel seen.
Upload your Heart Warrior's Photos
Please upload at least 3 different photos. We recommend high-resolution images as well as including different stages of the Warrior's life (hospital, childhood, present day).
Photo 1
Photo 2
Photo 3
Do you permit Ollie Hinkle Heart Foundation to use the submitted image/s and story for marketing purposes (social media, website, printed materials, etc)?
Yes
No
Would you like to be tagged in any social media posts about your Warrior?
Yes
No
If your story and warrior are included in a printed Warrior Card, do you want a copy of that card?
Yes
No
Would you like them to be mailed to the address you previously provided?
Yes
No
Please provide a different address for us to mail the card.
Contact Information