Sydney Lerman Pediatric Hospitality Program Questionnaire

If your child will be hospitalized soon, please complete this questionnaire. Once the questionnaire is submitted, Sydney, Carly, and other volunteers will create your customized basket and send it to you.

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* 1. First and last name of child having surgery:

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* 2. Child's Pronouns:

He/Him

She/Her

They/Them

He/They

She/They

Other (please specify)

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* 3. Child's Birthday:

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* 4. Child's Grade:

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* 5. Child's Condition/Diagnosis:

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* 6. Parent / Guardian Info (Primary Contact):

First Name:

Last Name:

Cell Phone Number:

Email:

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* 7. Parent/Guardian Info:

First Name:

Last Name:

Cell Phone Number:

Email:

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* 8. Mailing Address: (Due to current hospital guidelines, we need to send care packages directly to you at your home.)

Name

Street Address

City

State

Zip Code

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* 9. Have you been a recipient of a hospital care package in the past?

Yes

No