Family Partner Application First Name Last Name Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code E-mail Address Secondary E-mail Address Primary Phone Number Secondary Phone Number Birthday Name of the Patient(s) with whom you have experienced St. Louis Children's Which locations have you had services at? St. Louis Children's Hospital (off Kingshighway) Children's Specialty Care Center (CSCC at Mason Rd) Children's Hospital at Missouri Baptist Hospital Children's Hospital at Progress West Hospital Other If other, please describe in detail: In which area of the St. Louis Children's Hospital have you or your child been seen (check all that apply)? Inpatient Floors Ambulatory Procedure Center (APC) Radiology Outpatient Labs Pulmonary Function/Heart Station PAWS - Pediatric Acute Wound Service Same Day Surgery Emergency Unit Therapy Services Pharmacy Outpatient Clinic Eye Center Audiology Dialysis Center None In which area of the Children's Specialty Care Center have you or your child been seen (check all that apply)? Ambulatory Procedure Center (APC) Radiology Outpatient Labs Pulmonary Function/Heart Station PAWS - Pediatric Acute Wound Service Same Day Surgery Therapy Services Pharmacy Outpatient Clinic Audiology Dialysis Center None In which locations have you had Emergency Services at (check all that apply)? St. Louis Children's Hospital (off Kingshighway) Children's Specialty Care Center (CSCC at Mason Rd) Children's Hospital at Missouri Baptist Hospital Children's Hospital at Progress West Hospital Other If other, please describe in detail: If you have inpatient experience, please tell us which floor (check all that apply)? Neurology/Neurosurgery/Neurorehabilitation (12th Floor) Post Surgical/Burns/Wound Care (10th Floor) Hematology/Oncology (9th Floor) Bone Marrow Transplant Unit (9th Floor) General Medicine/Hematology (8 East) General Medicine/Gastrointestinal Disease (8 West) Pulmonology (7 East) Heart Center (7th Floor) Pediatric Intensive Care Unit (PICU) Neonatal Intensive Care Unit (NICU) Pediatric Inpatient at Missouri Baptist Pediatric Inpatient at Progress West How often do you visit any St. Louis Children's location? Regularly-scheduled appointments at least every 6 months Unplanned infrequent visits Other If other, please specify: How much time do you prefer to volunteer as a Patient or Family Partner (check all that apply)? Short-term projects, 1-4 meetings total Steady commitment to either a long-term project or an established committee Patient and Family Centered Care Council (2-year commitment, monthly meetings) Please check each statement that is true about you: I live farther away then 1 hour drive from St. Louis Children's Hospital I am a bereaved parent or family member We moved to St. Louis for St. Louis Children's Hospital I speak another language then English I have served as a parent or patient advisor before I have experience with organ transplantation If you speak another language, what language do you speak? Please tell us a little about you and your family: Why are you interested in becoming a Family Partner? How did you hear about our program: A physician (please identify below) A staff member (please identify below) Social Media A friend St. Louis Children's Hospital Website Other (please clarify below) If referred please write name below so we can thank them:
