PainPals: A pen pal program for kids with pain

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* 1. Contact information for the Pediatric Pain Warrior

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number

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* 2. Contact information for the Pediatric Pain Warrior's parent or caregiver

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number

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* 3. How old is the Pediatric Pain Warrior?

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* 4. Please list the Pediatric Pain Warrior's health conditions.

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* 5. What's the preferred communication method for the Pediatric Pain Warrior to communicate with their PainPal? (1=most preferred, 3=least)

Email

Snail mail

Phone

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* 6. How often would the Pediatric Pain Warrior be interested in connecting with their PainPal?

Once a week

Once every two weeks

Once a month

Once every two months

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* 7. Please list some of the Pediatric Pain Warrior's interests and hobbies (music, videogames, TV shows, sports -- anything!).

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* 8. U.S. Pain connects children with pain to one another and suggests guidelines for the PainPal relationship. It is not responsible for the behavior of participants or the content of their communications with one another. Parents and caregivers must monitor the interactions as necessary. If you have concerns about a participant, please email pediatricpainwarrior@uspainfoundation.org.

By clicking yes, I acknowledge and agree to the above.

Yes