Children's Hospital - Patient Stories Form

We appreciate your willingness to share your story. Please fill out the form below.

* = Required Fields

Patient Name*
Patient Date of Birth
Patient Photo	*.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff
Parent/Guardian Name
Address
City
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code	-
Phone	() - ext.
E-mail
Preferred method of communication Text Email Phone Call
Briefly describe what brought you to Children's of Mississippi (4-5 sentences).
Who were the doctors, nurses, or staff that you or your child remembers and why?
What is the likely forecast of your child's disease or ailment?
Tell us about your child's likes, dislikes, hobbies, and interests.
Does your child/family have a Mississippi college sports team affinity (Ole Miss, MSU, etc.)?
Is there any additional info that you would like to share?
Which of the following would you be interested and/or comfortable participating in? Having a story written about and photos taken of your child/family Attending a fundraising event as a Children's representative (not necessarily speaking to a crowd) Telling your story to a crowd (public speaking) Sharing your story on recorded video Sharing your story on live radio Attending a sporting event Visiting fundraising partners/sponsors to encourage them in their fundraising efforts Creating artwork for various collateral materials
I would like to receive information about upcoming Children's of Mississippi events and news. Yes