Stollery Story Squad Join the Squad - Online enrollment form Question Title * 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? OK Question Title * 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? OK Question Title * 3. What school system is your Stollery kid(s) enrolled in? Public school Catholic school Private school Homeschool N/A Other (please specify) OK Question Title * 4. Stollery story (a brief description of what brought your child to the Stollery and how they're doing today): OK Question Title * 5. Siblings (if applicable) Sibling 1: Name: Sibling 1: Birthdate: Sibling 2: Name: Sibling 2: Birthdate: Sibling 3: Name: Sibling 3: Birthdate: OK Question Title * 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: OK Question Title * 7. Parent/guardian #1: preferred method of communication? Email 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) OK Question Title * 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: OK Question Title * 9. Parent/guardian #2: preferred method of communication? Email 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) OK Question Title * 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 (newsletters, online content, etc.) Community engagement (Miracle Treat Day, parades, etc.) All opportunities OK Question Title * 11. If you're only comfortable sharing your Stollery story as part of your workplace partnership, please identify your workplace below. OK Question Title * 12. 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: OK Question Title * 13. 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 No OK Question Title * 14. Would you like to receive our monthly email newsletter, Bear Facts? Yes No OK Question Title * 15. Please upload a few photos of your Stollery kid that we can add to your file. JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Please upload a few photos of your Stollery kid that we can add to your file. OK Question Title * 16. Please upload a few photos of your Stollery kid that we can add to your file. JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Please upload a few photos of your Stollery kid that we can add to your file. OK Question Title * 17. Please upload a few photos of your Stollery kid that we can add to your file. JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Please upload a few photos of your Stollery kid that we can add to your file. OK DONE