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

Child's Name*	*
Child's Age (in months or years)
Parent/Guardian Name*	*
Parent/Guardian Phone*	() - ext.******
Parent/Guardian E-mail*	*Invalid Email
Parent/Guardian Address*	*
City/State/Zip* City * State 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 * Zip Code - ***
Relationship to Child/Patient*	*
In which Children's of Mississippi facility has this child/patient received care? Please select all that apply. Children's of Mississippi – Hospital (Jackson) Children's of Mississippi Center for Cancer and Blood Disorders (Jackson) Children's of Mississippi – Specialty Clinics (Jackson) Children's of Mississippi – Specialty Clinics (Meridian) Children's of Mississippi – Specialty Clinics (McComb) Children's of Mississippi – North Mississippi Medical Center (Iuka) Children's of Mississippi – North Mississippi Medical Center Children's Clinic (Tupelo) Children's of Mississippi – Batson Kids Clinic (Jackson) Children's of Mississippi – Bay St. Louis Clinic (Bay St. Louis) Children's of Mississippi – Clinic (Gulfport) Children's of Mississippi – Clinic (Biloxi) Children's of Mississippi – Clinic (Hattiesburg) Children's of Mississippi – Clinic (Greenwood) Children's of Mississippi – Clinic (Flowood)
Select the department of care that the child/patient received	Cardiology Endocrinology Hematology/Oncology NICU/Neonatology Nephrology Neurology Pulmonology Urology Other
If Other, please list the Department here.
What would make them a great ambassador for Children's of Mississippi?
Who are the doctors, nurses or staff that you or your child enjoys interacting with and why?
Please select any of the following Children's of Mississippi partnerships that your family has a relationship or affinity with. Ace Hardware CEFCO Costco Credit Unions Dairy Queen Game Stop JOANN Fabric's Hershey Kiwanis Clubs Knight-Swift Transportation Logging/Forestry Industry Love's Travel Stops Marriott Hotels McLane Company Ollie's Bargain Outlet Panda Express Phi Mu Sorority Re/Max Sigma Alpha Epsilon Fraternity Topgolf Walmart and Sam's Club University of Mississippi Mississippi State University University of Southern Mississippi Mississippi College
If you selected any of the above, please describe the relationship/affinity between the patient family and company.
Has your child served as a representative for another organization? If so, please describe the organization(s) and duties performed.
Please share with us your child's likes, hobbies or favorite activities.
Please upload a photo of your child	*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf, *.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff
Is there anything else you would like to share with us as we consider your child's nomination to become a Children's of Mississippi ambassador?
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