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:

ToddlerYouthAdult

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: