Patient Stories Form

Patient Date of Birth

Parent/Guardian Name

Preferred method of communication

Text

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

Mississippi Miracles Radiothon