Kid Captain Nomination Form

Your Information (as the Nominator)

First Name

Last Name

Phone Number

Email Address

Your relationship to the patient:

ParentLegal Guardian

Has the patient previously been selected as a Kid Captain with Blank Children's Hospital?

YesNo

Patient's Information

Patient's First Name

Patient's Last Name

Home Street Address

City

State

Zip Code

Patient's Age (must be at least 4 years old)

Patient's T-shirt Size
(please specify toddler, youth or adult sizing)

Are there any accessibility or accommodation needs for the patient or accompanying family members to be considered? (e.g., sensory, mobility, temperature regulation)

Time frame the patient received treatment at Blank Children's Hospital (or any of our clinics/departments):

Tell us about your child's diagnosis and treatment at Blank Children's Hospital:

Tell us how your child has inspired others through their medical journey:

How we ensure your data is secure