First Name

Last Name

Approximate age

Phone

Email

Suburb

State

Post Code

Description (occupation/gender/lifestyle etc)

Any quotes you are happy for us to share

Please include any photographs (in jpeg format) that can be used to help tell your story.

Is there anything else you would like us to know?

Please indicate if you would like to participate and if you are available to be contacted by Heart Research Australia for media opportunities.

I would like to help promote REDFEB and am available to be contacted throughout January and February*I am unable to help for 2023 but please keep me in mind for next year.I only want to share my story on the Heart Research Australia website and social media

There are various ways your story can be used in the media such as online, radio and TV interviews or in the newspaper. Please indicate your preferred method(s) of promotion:

RadioTVOnline MediaNewspaper/MagazineI am comfortable with being interviewed live for radio or TV opportunitiesI am willing to participate in creating a video testimonial to share my story