Ambassador Nomination

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* 1. Your name

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* 2. What is your relationship to the patient you are nominating?

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* 3. Patient's name (first and last)

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* 4. Patient's gender

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* 5. Patient's date of birth

Date

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* 6. What is the patient's diagnosis?

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* 7. Who is the patient's Mercy Children's physician?

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* 8. Please provide one or two other Mercy Children's employees who could act as a reference for this patient. (Name and department)

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* 9. Why should this child be an ambassador?

Please type a brief description of the child and why he/she would make a good ambassador. Please include information such as activities he/she is involved in, his/her personality, his/her overall story with Mercy Children's and his/her ability to share it in public and how he/she is around other people. Please also include information about the child's family (who he/she lives with, siblings etc...) and any other information you believe would be important to the nomination.

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* 10. Parent / guardian contact information

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