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Main Content
FAST Application Form
Children's of Mississippi Family Advisory Support Team (FAST)
Membership Application
Name
*
Phone
(
)
-
ext.
Address
*
City/State/Zip code
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
-
Email
*
Communication preference
*
Phone
Email
Mail
Please briefly describe your child's medical story
List areas of Children's Hospital service(s) you've experienced
Emergency Department
Inpatient
Primary Care
PICU
NICU
Surgery
Oncology/Hematology
Outpatient Clinic(s) (please list)
If outpatient clinic(s), please list:
I am a Batson Children's Hospital:
*
Family member (specify below)
Caretaker (specify below)
Sibling
Physician
Employee
Other (specify below)
Please specify:
Are you able to make a commitment to attend monthly team meetings and additional time (outside of FAST meetings) on a periodic basis for projects, focus groups and committee work?
Yes
No
Please briefly share why you would like to be a part of the FAST at Batson Children's Hospital
*
Hospital Recommendation
We would like to ask a healthcare professional to support your application. Please provide us the name of a doctor, nurse, child-life specialist, social worker, or staff member who would recommend you.
Name
Phone
(
)
-
ext.
or Email
Please note: Council members are considered volunteers of the hospital and are subject to a background check by the hospital’s Volunteer Services Department.