Stollery Story Squad Survey

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* 1. Stollery kid #1:

Last name:

First name:

Birthdate:

Medical condition(s)/diagnosis:

Primary Stollery doctor(s):

Time spent in Hospital (days, weeks, months, etc.):

Surgeries/procedures:

Interests (sports, music, cars, etc.):

Did they have a wish granted through Make-A-Wish?

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* 2. Stollery kid #2 (if applicable):

Last Name:

First Name:

Birthdate:

Medical condition(s)/diagnosis:

Primary Stollery doctor(s):

Time spent in Hospital (days, weeks, months, etc.):

Surgeries/procedures:

Interests (sports, music, cars, etc.):

Did they have a wish granted through Make-A-Wish?

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* 3. What school system is your Stollery kid(s) enrolled in?

Public school

Catholic school

Private school

Homeschool

N/A

Other (please specify)

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* 4. Stollery story (a brief description of what brought your child to the Stollery and how they're doing today):

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* 5. Siblings (if applicable)

Sibling 1: Name:

Sibling 1: Birthdate:

Sibling 2: Name:

Sibling 2: Birthdate:

Sibling 3: Name:

Sibling 3: Birthdate:

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* 6. Parent/guardian #1:

First name:

Last name:

Email:

Primary phone number:

Workplace (if you work outside your home):

Home address:

City:

Province:

Postal code:

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* 7. Parent/guardian #1: preferred method of communication?

Cell phone - text

Cell phone - call

Home phone - call

No preference | Any of the above

Parent/guardian #2 should be our primary contact

Social media (platform & user name)

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* 8. Parent/guardian #2:

First name:

Last name:

Email:

Primary phone number:

Workplace (if you work outside your home):

Home address:

City:

Province:

Postal code:

Question Title

* 9. Parent/guardian #2: preferred method of communication?

Cell phone - text

Cell phone - call

Home phone - call

No preference | Any of the above

Parent/guardian #1 should be our primary contact

Social media (platform & user name)

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* 10. Please indicate which opportunities you’re interested in: (Please check all that apply)

External media (radio, TV, newspaper, etc.)

Public speaking (events, store visits, corporate meetings, etc.)

Stollery media (HEROES magazine, newsletters, online content, etc.)

Community engagement (Miracle Treat Day, parades, etc.)

All opportunities

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* 11. Do you have any other connections with the Stollery? (Please check all that apply)

My kid(s) are Stollery Superstars (youth fundraisers)

I'm a donor

I personally fundraise for the Stollery

I'm a volunteer (Stollery Women's Network, general volunteer)

I'm a Stollery Children's Hospital staff member

I work for a company that supports the Foundation:

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* 12. Expressed Consent to Email

In order for the Stollery Children’s Hospital Foundation to communicate with you via email and continue sending you electronic news and information pertaining to the Foundation and the Stollery Children’s Hospital, please provide your expressed consent below.

Yes

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* 13. Would you like to receive our monthly email newsletter, Bear Facts?

Yes

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* 14. Please upload a few photos of your Stollery kid that we can add to your file.

JPG, JPEG file types only.

Choose File

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* 15. Please upload a few photos of your Stollery kid that we can add to your file.

JPG, JPEG file types only.

Choose File

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* 16. Please upload a few photos of your Stollery kid that we can add to your file.

JPG, JPEG file types only.

Choose File

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* 1. Stollery kid #1:

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* 2. Stollery kid #2 (if applicable):

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* 3. What school system is your Stollery kid(s) enrolled in?

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* 4. Stollery story (a brief description of what brought your child to the Stollery and how they're doing today):

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* 5. Siblings (if applicable)

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* 6. Parent/guardian #1:

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* 7. Parent/guardian #1: preferred method of communication?

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* 8. Parent/guardian #2:

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* 9. Parent/guardian #2: preferred method of communication?

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* 10. Please indicate which opportunities you’re interested in: (Please check all that apply)

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* 11. Do you have any other connections with the Stollery? (Please check all that apply)

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* 12. Expressed Consent to Email In order for the Stollery Children’s Hospital Foundation to communicate with you via email and continue sending you electronic news and information pertaining to the Foundation and the Stollery Children’s Hospital, please provide your expressed consent below.

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* 13. Would you like to receive our monthly email newsletter, Bear Facts?

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* 14. Please upload a few photos of your Stollery kid that we can add to your file.

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* 15. Please upload a few photos of your Stollery kid that we can add to your file.

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* 16. Please upload a few photos of your Stollery kid that we can add to your file.

* 12. Expressed Consent to Email

In order for the Stollery Children’s Hospital Foundation to communicate with you via email and continue sending you electronic news and information pertaining to the Foundation and the Stollery Children’s Hospital, please provide your expressed consent below.