Miracle Kid Nomination Form
Staff, community partners, and families are invited to nominate a Miracle Kid to share their story and represent the impact of care at our hospital. One child will be selected as our local 2027 CMN Champion, while additional children may be chosen to serve as CMN Ambassadors throughout the year. Selected Miracle Kids will have a story written about their experience at our hospital, highlighting their journey and the care they received. These stories may be featured across a variety of platforms, including social media, our website, USA Health emails, and print communications shared with donors and community partners. In addition, selected patients and their families may have opportunities to share their story through video, virtual appearances, or at community and fundraising events.
Nominator Information
First Name*
*
Last Name*
*
Store Number
Email*
*
example@example.com
Relation to Patient
Parent
Sibling
Extended family member
Friend
Physician/Care Team
Other
Will the champion will be under 18 years of age by January 1, 2027
Yes
No
Patient’s First and Last Name*
*
Patient’s Birthdate (mm/dd/yy)*
*
-
Month
-
Day
Year
Date
Parent/Guardian’s Name
Parent’s Email
example@example.com
Parent’s Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient’s Gender*
*
Male
Female
Non-binary
Prefer not to say
Other
Age when child was treated at USA Health Children's & Women's Hospital?
What initially brought the patient to USA Health*
*
Please share about the patient's time at USA Health.
How is the child doing today?
Please list any instrumental staff members and department(s) involved in the patient's care.
Why do you think this patient should be a Patient Ambassador?
Would the patient and their family be comfortable having their story shared in print or digitally?
Yes
No
Unknown
Both the child and guardian are willing and able to interact well with media and in front of an audience...
Yes
No
Unknown
Are thereany known controversial situations surrounding the child or their care?
Yes
No
Unknown
Submit Nomination
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