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Children’s of Mississippi – Patient Ambassador Nomination Form

Thank you for your interest in the Children’s of Mississippi Patient Ambassador Program. Children’s of Mississippi Ambassadors are patient families who feel led to share their personal stories, fundraise, and serve as a team of representatives for Children’s of Mississippi. Ambassadors and their families raise awareness and inspire community support to benefit Mississippi’s only children’s hospital.

As an Ambassador family, you will be invited to share your personal Children’s of Mississippi health story in a way that you feel most comfortable. Examples include but are not limited to: 

  • Attending local fundraising events​  
  • Participating in speaking engagements ​  
  • Sharing your story on the radio, in local magazines and on TV​  
  • Fundraising online through your Ambassador page​  
  • Sharing encouraging messages on your social media pages​  
  • Thanking donors by creating artwork, making videos, writing notes, or making phone calls​  

A parent or legal guardian must submit this form. Nominations are due Friday, June 28, 2024.

* = Required Fields

Parent/Guardian Phone*() - ext.   
Zip Code -  
In which Children's of Mississippi facility has this child/patient received care? Please select all that apply.

Please select any of the following Children's of Mississippi partnerships that your family has a relationship or affinity with.

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