CSH Ambassador Nomination Form
Do you know a child who has faced more than his or her fair share of medical challenges, yet still inspires others with their determination, strength and smile-through-it-all approach to even the toughest days? The Children’s Specialized Hospital team wants to hear from you! Nominate your child (or one near and dear to you) to be a ambassador child. What is a ambassador child? These are special kids with incredible stories who are selected, along with their families, to serve as ambassadors to Children’s Specialized Hospital and Children's Miracle Network. In this role, they help to raise awareness and generate funds by participating in corporate and fundraising events throughout the year and appearing in various marketing materials. Children's Specialized Hospital Foundation raises more than $8 million each year for CSH. By sharing their experience, showing their gratitude for their care providers and helping to spread the word about the importance of pediatric hospitals, ambassador children and their families are an important part of this effort. Ready to nominate your ambassador? Fill out the form below.
Contact Information
*
Title
First Name
Last Name
Email
*
example@example.com
What is your relationship to the patient nominee?
*
Please Select
Parent
Sibling
Extended Family Member
Provider
Children's Employee
Friend
Other
Patient's First and Last Name
*
First Name
Last Name
Patient's Birthday
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian's Name
*
First Name
Last Name
Parent's Email
*
example@example.com
Parent's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Adress
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Gender
*
Male
Female
Non-binary
Other
Does the patient have siblings
Yes
No
If so, what are their names and ages?
Does the patient have any special hobbies or talents? If so, what are they? (type N/A if not applicable)
*
Patient's Ethnicity
*
Please Select
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
White
Other
Age when child began treatment at CSH
Please Select
0-6 months
7-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Primary Children's location where the child received treatment
*
New Brunswick (Inpatient)
Toms River (Long Term Care)
Mountainside (Long Term Care)
Bayonne
Clifton
East Brunswick
Eatontown
Egg Harbor
Hamilton
Newark
Toms River (Outpatient)
Union
West Orange
Somerset
What initially brought the patient to Children's?
*
What is the patient's diagnosis?
*
Please share the patient's story of his/her time at CSH.
*
How is your child doing today?
*
Please list any instrumental staff members and department(s) involved in the patient's care
What has been the hardest part of the patient's medical journey?
Why do you think this patient should be an ambassador child?
*
From where were you referred to fill out this form?
Please include a recent photo of the nominee
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