Children's of Mississippi Family Advisory Support Team (FAST) Membership Application

Children's of Mississippi Family Advisory Support Team (FAST) Membership Application
Name*
Phone	() - ext.
Address*
City/State/Zip code*	-
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.

Children's of Mississippi