Children's of Mississippi

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FAST Application Form

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

Name* 
Phone() - ext.
Address* 
City/State/Zip code*  -  
Email* 
Communication preference*

Please briefly describe your child's medical story
List areas of Children's Hospital service(s) you've experienced






If outpatient clinic(s), please list:
I am a Batson Children's Hospital:*




 
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?
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.