Special Visitors Application

Special Visitors Application

Completion of this form does not guarantee you a scheduled date or time, but starts the process with our department. Once this form is received, you will be contacted directly by our department to continue the process and schedule going forward.
Contact Person:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Group/Organization:*
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.
Contact Preference (NOTE: Scheduling confirmation and reminder information will be sent through email regardless so information can be kept on hand until needed):*

EmailPhone

Does your organization have social media pages that Wesley Children's Hospital and/or its affiliate organizations can tag in any posts made from our marketing department? (Personal social media pages CANNOT be used!)
Number of Persons in Group:*
A maximum of 10 individuals will be allowed per group.
Age Range of Group Members:*
No individuals under the age of 12 will be permitted to visit.
All individuals attending with your group for your visit must fill out an individual attestation form, which will be provided in the confirmation email sent from the Child Life department when your group is officially scheduled. Please make sure all attendees fill this form out BEFORE the day of your visit.

Vaccination Status
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 ALL persons in your group up-to-date on standard immunizations (commonly known as "childhood immunizations")?*

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, 2024?*

YesNoI'm not sure
Have ALL persons in your group received the FLU vaccination for the 2025 - 2026 season?*

Yes (individual group members will fill out an attestation form to verify this)No (Each person visiting with your group will either need to have this done before your scheduled date and confirm on their individual submission, or they will be required to wear a mask at all times while on the units.)
By signing, you acknowledge that as the representative of this group, you will inform all group members of the above information and make sure that all are in compliance of the guidelines.*

Wesley Children's Hospital is a for-profit facility that is required to follow compliance and legal regulations set for this type of facility. The below requirements are in place to ensure these regulations are met and that our facility stays in good standing. If you have questions about any of the below requirements, please don't hesitate to reach out to our team!
REQUIREMENTS FOR ALL PROVIDED ITEMS

IF ANY OF THE BELOW REQUIREMENTS ARE NOT MET, ITEMS MAY NOT BE PASSED OUT TO PATIENTS.
1. EACH INDIVIDUAL ITEM must have a sticker/label with the group/organization's name or logo on them (printed label, sticker, etc.). This ensures families know who provided the item and that it did not come directly from the hospital.
2. Labels CANNOT include any type of promotion (ex. $5 off a purchase, contact for business needs, etc.). They may include your logo and a statement of "This item was donated by ....."
3. All items must be unwrapped!
4. All items must be new and in original packaging.
5. We serve patients 0-18, so any gifts for all ages are much appreciated!
6. Although recreation items (ex. Bikes, scooters, etc.) are fun for children to play with, these are not items we can hand out as a hospital due to safety risks. We are unable to accept these as part of any drop-off.
7. Because we serve a diverse population of patients, we are unable to pass out anything promoting specific religions/beliefs (no specific images, verses, etc. should be included on or in donated items).
8. We are unable to accept any items that are intended to stay in the hospital for repeated use. Items that are donated will be sent home with patients as deemed necessary by the Child Life team.
ALL ITEMS PROVIDED WILL BE PASSED ON TO PATIENTS AND FAMILIES RECEIVING CARE.

WE ARE UNABLE TO ACCEPT ANY ITEMS INTENDED TO STAY AT OUR FACILITY TO BE REUSED.
NO TOYS/ITEMS WITH BUTTON BATTERIES, PLEASE!

***Please remember!! No latex is allowed to be brought into the hospital, including balloons!***

We prefer that no food is provided to our patients, as many are on dietary restrictions and cannot be given certain foods. For questions, call the Child Life office at 316-962-2177.
I have read the above requirements and understand if these are not met, I will not be able to provide my items.*

Clear
Select type of visit:*

Delivering goodies/gifts to patientsPresentation/PerformanceDonation of supplies/gifts
Anticipated length of visit*

Drop off only0 - 30 minutes30 - 60 minutes60 minutes - 2 hours2+ hours
Describe in detail what your plan is for this visit:*
List any materials/equipment you may need staff to provide (carts/wagons to haul, tables set up, etc.)*
Time needed for set up/clean up (this time will be factored into your scheduled time, so please plan set up and clean up to fit into this time.) Please put 0 if no time is needed.*

Many groups that collect items to donate often create social media pages and posts to encourage donations. If you choose to do this, these posts and pages CANNOT state they are for Wesley Medical Center directly. This leads donors to believe they are donating to a hospital-sponsored event. We greatly appreciate your willingness to provide for our patients and families, but it must be clear in your posting that your organization is choosing to do this, and is not a direct ask from the hospital. You can list your organization as the recipient, stating items will go to local hospitalized children, and can include a suggestion of frequently needed items.
By signing, you acknowledge the above information and agree to abide by what is stated.

Clear

We work to schedule all visits between 10:00 am and 4:00 pm, Monday through Friday.

Alternate arrangements may be possible depending on staffing availability, but this cannot be guaranteed.

Because our activity calendar fills up quickly, we highly encourage you to provide alternate dates as well. Scheduling is done on a first-come, first-served basis.
Selecting a date on this form does not guarantee you a visit on this date! Once your application is reviewed and approved by our staff, you will hear from us to set a time and date for your visit.
PREFERRED DATE OF VISIT*

MonthDayYear
Alternate Date 1

MonthDayYear
Alternate Date 2

MonthDayYear
Alternate Date 3

MonthDayYear
Preferred time of day (SELECT ALL AVAILABLE OPTIONS)*

Morning (10:00 am - 12:00 pm)Afternoon (12:00 pm - 4:00 pm)Other

I confirm that I am 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 with expected participants and affirm my group’s willingness to adhere to all of the guidelines. By signing below, you are agreeing to the above statement and are acknowledging that you are responsible for all members of your group while on campus.*
Should be Empty:

Special Visitors Application

Vaccination Status

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.