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Kid Captain Nomination Form
Your Information (as the Nominator)
First Name
Last Name
Phone Number
Email Address
Your relationship to the patient:
Parent
Legal Guardian
Patient's Information
Patient's First Name
Patient's Last Name
Patient's Age (must be at least 4 years old)
Home Street Address
City
State
Zip Code
Patient's T-shirt Size:
Toddler
Youth
Adult
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:
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