Affiliate Web Page Information Form

Redirecting you to a secure payment page…

Affiliate Information

First Name *

Last Name *

Job Title

Submit as a company

Company Name

Website

Phone 1

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Representative acceptance

I agree to allow HCMA/HCMAi to post this information on the affiliate web page. I understand that I may update this info as needed with written notice to to HCMA.

Media

If applicable, please provide your Facebook social media handle.

If applicable, please provide your Instagram handle.

If applicable, please provide the link to your YouTube channel.

Attach organization logo or photo

Notes

Please provide any other information here.

HCMA permissions & account creation

Data Privacy & Consent

Yes, I would like to receive communications from Hypertrophic Cardiomyopathy Association by email.

Yes, I would like to receive communications from Hypertrophic Cardiomyopathy Association by phone.

Yes, I would like to receive communications from Hypertrophic Cardiomyopathy Association by mail.

Yes, I would like to receive text messages from Hypertrophic Cardiomyopathy Association Because I have a big heart! Lisa and the team, thank you!

Yes, I consent to have Hypertrophic Cardiomyopathy Association share my data with a third-party service.

Create an account to save your information and access our online portal!

Password

Retype Password

Have an account? Log in

Secure Payment

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Affiliate Web Page Information Form