LPCH Patient Hero Program

1. Patient Hero Parent Contact Information (Please enter your name, phone number, and email.)

2. Patient Hero Name:

3. Age:

4. Hometown:

5. Who referred you to the Patient Hero Program?

6. Share a brief (four- or five-sentence) summary of the Patient Hero’s connection to our hospital: *This question is required.

7. Are there particular doctors, nurses, specialists, or other staff members who made a positive impact on your family’s experience at our hospital? *This question is required.

8. Would you (and/or the Patient Hero if appropriate) be willing to share your family’s story with our supporters in the form of a very brief speech at a staff/board meeting, corporate sponsor’s office, or other gathering? This is not required, but a nice way for our community to meet the Patient Heroes. *This question is required.

9. If you answered “yes” above, do you have any specific requests for giving a speech? (e.g. audience size limit, no weekdays, etc.)

10. Would you be comfortable with us sharing the Patient Hero’s story in fundraising materials? Please check all that apply. *This question is required.

11. Please attach photos or videos of your child that show his/her personality and favorite activities. You can upload multiple photos. The file size limit for each upload is 2 MB. If you have more photos to share, please email them directly to Megan Alpers at Megan.Alpers@lpfch.org. Thank you!

Image 1 *This question is required.

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12. Image 2

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13. Image 3

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14. Image 4

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