Ambassador Application

LifeSource Ambassador Profile
Hnub no lub hnub tim*
MM slash DD slash YYYY
Npe*
Thawj Kawg
Hnub Yug*
MM slash DD slash YYYY

mm/dd/yyyy
kev ua hauj lwm
xov tooj*
Thov xaiv seb tus xov tooj uas koj nkag mus saum toj no yog ib tug mobile, tsev los yog chaw ua hauj lwm? *
Lwm txoj xov tooj
Thov xaiv seb tus xov tooj uas koj nkag mus saum toj no yog ib tug mobile, tsev los yog chaw ua hauj lwm?
Email*
Chaw Nyob*
Chaw Nyob Chaw Nyob Kab 2 Zos Xeev Tsib tug leb qhia thaj tsam yus nyob

Kev sib raug zoo rau txoj kev sib LifeSource/Pub lub neej
Kev sib raug zoo rau Donation/Transplantation*
- Kuv yog ib tug nyob hauv ib tsev neeg pub.
- Kuv yog ib tug neeg tau txais kev pab.
- Kuv yog ib tug nyob hauv tsev neeg.
- Kuv tabtom tos ib lub txiv kab ntxwv transplant.
- Kuv yog ib tug nyob pub.
- Lwm.
Yog hais tias lwm tus, thov muab kev sib raug zoo rau donation/transplantation hauv qab no. *
Kuv kev sib raug zoo los pub*
Donor lub npe*
Tus Neeg Tau Kev Pab Lub Npe*
Kuv kev sib raug zoo rau tus neeg tau txais kev pab*
Hnub Donation*
MM slash DD slash YYYY
Donor lub tsev kho mob*
Hom transplant*
Piv txwv li: Lub plawv, lub raum, lub ntsws, qhov muag, cov nqaij mos, cov nqaij mos.
Hnub Hloov Transplant*
MM slash DD slash YYYY
Transplant Center*

Tsis Pub Lwm Tus Paub Thiab Kev Tso Cai
Ua ib tug LifeSource Ambassador, peb nug tias koj ua raws li ib tug code ntawm ethics. Cov ethics yuav tsum qhia koj tus cwj pwm, raws li ib tug ntawm peb lub luag hauj lwm fundamental kev txhawj xeeb txog confidentiality. Thaum koj ua haujlwm pub dawb rau koj ua haujlwm pub dawb LifeSourceTej zaum koj yuav tau nyob rau tej lub ntees, muaj kev tsis pub leej twg paub. Tej zaum koj qhov chaw ua hauj lwm tej zaum yuav nqa koj cov ntaub ntawv qhia txog koj tus kheej txog cov neeg uas LifeSource pab raws li cov haujlwm ntawm cov haujlwm LifeSource los yog peb pab neeg. Peb code of Ethics lub xeev uas koj yuav tsis rov ua tej ntaub ntawv uas tsis pub leej twg paub rau leej twg. Tej nuj nqis uas koj yuav siv tau tej ntaub ntawv uas tau txais rau koj tus kheej kom zoo dua qub. Confidentiality yog ib txoj cai fundamental ntawm cov peb pab, thiab nws yog guaranteed los ntawm koj adherence rau peb LifeSource Ambassador rua cov miv nyuas. Thov kos npe rau tsab ntawv tsis pub leej twg paub hauv qab no ua ib feem ntawm koj daim ntawv thov Ambassador nrog LifeSource.
Tsis Pub Lwm Tus Paub
Lub Rooj Tswjhwm Saib cov Directors hu rau koj paub cov Disease fact tias tag nrho LifeSource Ambassadors xav tias ib obligation los tsim lawv tus kheej raws li tus txheej txheem los tuav tag nrho cov ntaub ntawv txhawj xeeb txog cov neeg mob, hloov, thiab cov neeg tau txais kev pab. Nyob rau ib lub hauv paus pib, LifeSource Ambassadors tej zaum yuav tau mus saib tau cov ntaub ntawv kho mob los ntawm kev kho mob LifeSource cov kev pab cuam transplant programs thiab hloov mus rau tom tsev kho mob. Nyob tsis muaj ntees yuav muaj ib lub ntees LifeSource Ambassador divulge rau txhua tus neeg tsis tau txais kev pab hais txog laboratory, kev kho mob, surgical, social, lossis lwm yam ntaub ntawv.

LifeSource Ambassadors yuav tsum refrain ntawm revealing tej ntaub ntawv txhawj xeeb txog cov neeg ua hauj lwm los yog cov lag luam ua hauj lwm. Unauthorized tso tawm txhua yam thiab tag nrho cov lus qhia ntawm cov lus qhia uas tsis pub lwm tus paub LifeSource tej zaum yuav ua tau kom muaj kev sib raug zoo nrog lwm tus.
Kuv tau nyeem cov nqe lus saum toj no, kuv nkag siab cov ntsiab lus, thiab kuv pom zoo, tsuas yog tso cai, nrog rau cov lus qhia uas tsis pub lwm tus paub.
Tsis Pub Lwm Tus Paub Kos Npe Kos Npe*
Kev Tawm Diam duab Consent*
LifeSource Tej zaum yuav siv Ambassador duab rau kev tawm qhov chaw pab qhia tej yam zoo peb Ambassadors muaj nyob rau hauv lub zej zog. Thov xyuas "tsis yog" yog tias koj TSIS xav tau cov duab ntawm koj tus kheej.
- Kuv muab rau kuv LifeSource Tso cai siv tej duab ntawm kuv tus kheej rau kev tawm.
- KUV TSIS KAM MUAB TSIS PUB KUV MUAB RAU LifeSource Tso cai siv tej duab ntawm kuv tus kheej rau kev tawm.
Media Consent*
- Kuv muab rau kuv LifeSource tso cai siv kuv lub npe/Diam duab yav tom ntej los yog muab rau hauv xov xwm.
- KUV TSIS KAM MUAB TSIS PUB KUV MUAB RAU LifeSource tso cai siv kuv lub npe/Diam duab yav tom ntej los yog muab rau hauv xov xwm.

Ambassador Txawj thiab Nyiam
Sau kom tiav cov kev txawj ntse thiab kev soj ntsuam hauv qab no — peb lub hom phiaj yog los tsim txuj uas phim koj keeb kwm yav dhau los thiab txuj ci rau lub hom phiaj ntawm lub hom phiaj ntawm LifeSource. Yuav kom peb ua li ntawd, peb yuav tsum paub ntau npaum li cas txog koj. Thaum cov ntaub ntawv yog xaiv, nws yuav pab peb nyob rau hauv peb kev siv zog los muab cov lus ntawm donation.
Thov muab koj vim li cas thiaj pab dawb rau peb:*
Koj puas muaj ib qhov zoo sib xws yav dhau los LifeSource thiab/los yog pab dag zog dawb rau peb? *
Yog muaj, luv luv piav koj qhov zoo sib xws LifeSource los yog pab dag zog dawb rau peb. *
Koj tau ua dab tsi yav dhau los koj tau hais lus (yog muaj)? *
Koj nyiam sib koom koj donation/transplant zaj dabneeg? *
Koj puas muaj affiliations nrog ib pawg lossis koom haum? (e.g., tsev teev ntuj pab pawg neeg, cov pab pawg neeg, cov pab pawg neeg, cov pab pawg neeg, cov pab pawg neeg tseeb) *
Thov sau lwm yam hobbies, talents, peev xwm, sib txuas, los yog nyiam koj muaj. *
Thov muab 100 – 300 lo lus piav txog koj tej kev pub dawb thiab transplantation. *
Dab tsi coj mus rau koj transplant? Koj tsev neeg thiab tej phooj ywg raug kev puas siab puas ntsws los ntawm koj tus mob? Koj lub neej raug tej yam? Koj ua dab tsi tam sim no uas koj tsis tau ua vim yog koj tus mob?
Thov muab 100 – 300 lo lus piav txog koj tej kev pub dawb thiab transplantation. *
Qhia rau peb txog koj qhov kev txiav txim siab los pub. Koj puas muaj ib qhov zoo sib xws rau tus neeg tau txais kev pab? Koj lub neej tej yam ua ntej thiab tom qab lub donation txheej txheem?
Thov muab 100 – 300 lo lus piav txog koj tej kev pub dawb thiab transplantation. *
Qhia rau peb ib yam dab tsi txog koj hlub ib tug. Koj hlub ib kis tseg? Ua cas peb thiaj txiav txim siab tau zoo? Cov txiv kab ntxwv/cov ntaub so ntswg tau pub? Koj xav li cas txog qhov no?
Thov muab 100 – 300 lo lus piav txog koj tej kev pub dawb thiab transplantation. *
Dab tsi coj mus rau qhov xav tau koj hlub ib transplant? Koj tau raug kev nyuaj siab li cas los ntawm koj tus hlub ib tug mob? Dab tsi yog ib yam uas koj hlub ib tug yuav ua tam sim no tias nws yuav tsis ua vim nws mob ua ntej lub transplant?
Thov muab 100 – 300 lo lus piav txog koj tej kev pub dawb thiab transplantation. *
Dab tsi coj mus rau transplant? Koj tsev neeg thiab tej phooj ywg raug kev puas siab ntsws li cas? Koj lub neej raug tej yam zoo li cas?
Thov muab 100 – 300 lo lus piav txog koj tej kev pub dawb thiab transplantation. *
Koj tau raug kov los ntawm donation/transplantation? Puas muaj tej yam xwm tshwm sim los yog kev sib raug zoo rau ib tug neeg tau txais kev pab los yog ib tug neeg tau txais kev pab?
T-shirt loj*

Kev Kub Ntxhov
Ambassador Name*
Thaum muaj xwm ceev, ceeb toom:*
Ua ntej thiab Lub Xeem Ntawm Kev Kub Ntxhov
Hu Xov Tooj Rau Cov Xov Tooj*
Chaw Nyob Ceev Ti Tes Ti Taw*
Chaw Nyob Chaw Nyob Kab 2 Zos Xeev / Xeev / Thaj av ntawd / Thaj av ntawd ZIP / Postal Code

ua ib tug LifeSource Ambassador hnub no.

Muaj ob peb kauj ruam yooj yim rau teb ua ib ambassador:

Step 1 of 6 – Contact Information

LifeSource Ambassador Profile

Kev sib raug zoo rau txoj kev sib LifeSource/Pub lub neej

Demographic Info

Tsis Pub Lwm Tus Paub Thiab Kev Tso Cai

Ambassador Txawj thiab Nyiam

Kev Kub Ntxhov