Member of the Month Nomination Form
Your Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Are you the patient's parent or legal guardian?
*
Yes
No
Name of patient you are nominating
*
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which hospital do they attend for treatment?
*
Are they still on active treatment?
*
Which programme are they on?
*
Burns
Cardiac
Chronic
NICU
Oncology
Are you happy to submit the patient's story and photographs of them with their beads, to be used on Social Media/Website/Literature used to promote the programme?
*
Yes
No
Tell us about who you would like to nominate and share their story in as much detail as you can. We know you know they are amazing, but you need to let us know why, so we can know too.
*
Upload a clear photo of the nominee with their beads
File Upload
*
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*
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