Special Visitors Application

Special Visitors Application

Each member of a visiting group needs to complete this form before their visit date!
Name:*

First NameLast Name
Phone Number*
Please enter a valid phone number. This will only be used if the child life team needs to contact you about any issues with your form.
Email:*
Please enter a valid email address. This will only be used if the child life team needs to contact you about any issues with your form.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Group/Organization you are visiting with:*
Visitors must be affiliated with an organization, foundation, or public group. If you are not affiliated, please contact the Child Life Department at 316-962-2177 to discuss other options.
If your group is not listed above, please type your group name and verify with your group organizer that you have a scheduled visit:
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Preference (NOTE: Scheduling confirmation and reminder information will be sent to your group's primary contact. You will only be contacted if there are any issues with your form.):*

EmailPhone

Vaccination Compliance
All group members planning to visit Wesley Children's Hospital's pediatric units must be current on their standard immunizations (these are most often required before starting school/completed in early childhood; DTaP, MMR, Varicella, Hepatitis, etc.).

For questions, please call the Child Life Department at 316-962-2177.
Are you up-to-date on all standard immunizations (those needed for school/early childhood; does NOT include flu or COVID-19 vaccine)?*

YesNo
FLU SEASON: Wesley Medical Center HIGHLY ENCOURAGES all individuals to have their flu vaccination complete before visiting during the respiratory season (November - April). Group members will need to have their flu shot completed before the visit, or will be required to wear a mask while visiting.
Is your scheduled visit date on or before October 31, 2026?

YesNoI'm not sure
Have you received the FLU vaccination for the 2025 - 2026 season?*

YesNo (You will either need to have this done before your scheduled date and confirm with Child Life staff, or will be required to wear a mask at all times while on the units.)
If you have any questions about these requirements, please call the Child Life department at 316-962-2177.
By signing, you confirm that you understand the requirements listed above and will either obtain a flu vaccine or will wear a mask while in the facility. This helps to protect both our patients admitted, as well as the staff caring for them.

I confirm that I am attending this visit as a representative of the above-mentioned group, and I have read the requirements for visitors to the Pediatric Unit at Wesley Children’s Hospital. I have reviewed these requirements confirm my willingness to adhere to all of the guidelines. By signing below, I agree to the above statement and acknowledge that I am responsible for following guidelines while on campus.*
Please verify that you are human.*
Should be Empty:

Vaccination Compliance