Children's of Mississippi

Children's of Mississippi

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Child Life Patient Special Event Request Form

Thank you for your interest in hosting a special event for our patients at Children's of Mississippi! Please review the following guidelines to ensure a positive experience for both our patients and your organization, then complete and submit the Patient Special Event Request Form below at least eight weeks prior to your requested visit.

Children's of Mississippi looks forward to partnering with community organizations in facilitating patient special events that are:

Highly engaging, therapeutic, and educational for children
Unique (we can only accommodate so many similar acts)
Developmentally appropriate for patients of all ages (infant-young adult)
Religiously and politically neutral
Physically and emotionally safe for patients, their families, and staff
Appropriate for available space

Guidelines

Patient special event visitors are escorted by a UMMC staff member at all times. Event visitors must be 18 years or older.
Due to patient confidentiality, patient special event visitors are NOT permitted to take pictures or videos of patients and families. Visitors may take photographs of themselves in areas approved and monitored by Child Life staff. Children's of Mississippi's Office of Communications and Marketing oversees requests for photographs or videos of patients.
Patient special event guidelines, scheduling availability, and confirmation of events are subject to change based on the current health status of our community and hospital policy.
Due to a fluctuating hospital census and patients' individual circumstances, we are unable to predict the number of patients available during your visit.
Groups of up to 10 visitors are accommodated. Groups larger than five may be divided into smaller groups during the event.
We encourage patient special event visitors to carpool due to parking availability. We are able to accommodate visitor parking in Garage C next to the Sanderson Tower. Bring your parking ticket with you to the Sanderson Tower entrance for a hospital representative to provide parking validation.
Oversized vehicle or bus parking requires approval before your visit.
Plan to arrive 15 minutes before your scheduled visit. If you are arriving late or need to cancel your visit, email ChildLife@umc.edu at your earliest convenience.
Dress appropriate for a hospital setting. Wear closed-toe shoes. Mascot and character costumes require approval by the Child Life department prior to your visit.
Refrain from the use of tobacco products and perfume/cologne prior to your visit.
Any items needed for visit must be provided by visiting group and will be reviewed by Child Life staff.
Due to food allergies and diet restrictions, food and beverage items are discouraged and require pre-approval prior to patient special events.
Patient special events are primarily scheduled for 1 hour on Monday-Friday between 10 AM-12 PM and 1 PM-3 PM.

Thank you again for your interest in visiting Children's of Mississippi and hosting a meaningful experience for our patients. We greatly appreciate your willingness to share your time, talents, and compassion with our patients and their families!

* - Required Fields

Name of Group*

Address

City/State/Zip

Contact Person*

Email Address*

Phone Number*

Number in Group (no more than 10)*

Ages (18+)

Preferred Date/Time of Visit (M-F, 1 hour between 10am-12pm or 1pm-3pm, weekends unavailable

First Choice* Date:

Time:

Second Choice* Date:

Time:

Please describe your patient special event/activity*

Affirmation:*

I affirm that all patient special event visitors have read the Children's of Mississippi Child Life Patient Special Event Guidelines and affirm each visitor's willingness to adhere to these guidelines.

As a representative of

Contact Name

Date*

By checking the Affirmation box above, I affirm that the information I have provided is correct and true, and that this checkbox represents my signature as the Contact Name listed.