Thank you for your interest in the Family Partnerships Program at Boston Children's Hospital. We appreciate your willingness to give back to the Boston Children's community. First Name* must provide value
Please enter your first name.
Last Name* must provide value
Please enter your last name.
Are you a Boston Children's Hospital:* must provide value
Patient
Parent
Grandparent
Guardian
Sibling
Other
Please indicate your relationship with the hospital.
If Other, please specify: If you chose 'Other,' please indicate your relationship with the hospital.
Street Address* must provide value
Example format: 300 Longwood Avenue, Boston, MA 02115
City* must provide value
Please enter your city of residence.
State* must provide value
AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS GU MP PR VI Please chose your state of residence.
COUNTRY Zipcode* must provide value
Please enter the zipcode of your residence.
Home Phone Number Please enter your home phone number.
Cell Phone Please enter your cell phone number.
Email Address Please enter your email address.
What Boston Children's Hospital locations do you or your child(ren) receive care at? Emergency Department
Inpatient Units (overnight stays)
Outpatient Units (clinic visits)
Primary Care
Martha Elliot Health Center
Satellite Clinics
Boston Children's Hospital Physician Office locations
Please check all boxes that apply to where your/your child visits.
If you or your child(ren) receive care at Boston Children's satellite locations, please mark the locations that you have visited/receive care at: Lexington
Peabody
Waltham
Please check all boxes that apply to where your/your child visits.
If you or your child(ren) receive care at a Boston Children's Physician Office location, please mark the location(s) that you have visited/receive care at: Brockton
Milford
North Dartmouth
Norwood
Weymouth
Please check all boxes that apply to where your/your child visits.
Please specify the inpatient unit(s), specialist(s) and/or satellite(s) where you/your child are seen.* must provide value
Please check all boxes that apply to where your/your child visits.
Please mark all of the clinics and/or departments where you or your child are, or have been, cared for: Adolescent Medicine
Allergy and Immunology
Brain Center
Cancer and Blood Disorders Center
Cardiology
Critical Care Medicine
Dentistry
Developmental Medicine
Emergency Department (ER)
Endocrinology
Gastroenterology, Hepatology
General Surgery
Genetics and Genomics
Gynecology
Heart Center
Infectious Diseases
Nephrology
Neurology
Neurosurgery
Newborn Medicine
Nutrition
Ophthalmology
Orthopedic Center
Otolaryngology and Communication Enhancement
Pediatric Transplant Center
Plastic and Oral Surgery
Primary Care
Psychiatry
Pulmonary and Respiratory Diseases
Rheumatology
Sports Medicine
If you or your child has had one or more inpatient stays at Boston Children's Hospital, please indicate the floor(s)/unit(s) where you stayed: 6NorthEast: Hematology, Oncology
6West: Stem Cell Transplant
7North: Neonatal ICU
7South: Medical/Surgical ICU
7West: General Medicine
8East: Cardiology/Cardiac Surgery
8South: Cardiac ICU
9NorthWest: Neuroscience
9East: General Medicine
9South: General Medicine
10East: Infant/Toddler Surgery
10South: Surgical/Solid Organ Transplant
10NorthWest: Surgical/Orthopedics
11South MICU: Medical ICU
11S ICP: Intermediate Care (Step Down)
Bader 5: Inpatient Psychiatry
Waltham 3W: Surgical
Waltham ICBAT: Waltham Psychiatry
If not listed above, please share any other clinics or inpatient units where you or your child receive(d) care.
After reviewing the "Ways to Give Back to Boston Children's Hospital" guide, please mark the areas that you are interested in participating in: Become a Family Partner:
Email surveys: At home, online, typically less than one-hour commitment per survey.
Focus Groups: In person or by phone, usually one-two hour commitment, may be one-time or a series of a few meetings.
Committees/Workgroups: Time commitment varies by project. Typically requires some in-person volunteer hours.
Virtual Advisory Council: Time commitment is extremely flexible. Constructive feedback provided for timely and relevant projects through a secure online forum.
Family Advisory Council: Time commitment is 2.5 hours every month for Council meetings (in-person attendance is preferable) plus approximately 1-3 additional volunteer hours per month for committee/workgroup participation. New members are added once or twice per year.
Family-to-Family Mentor: Available for certain departments/diagnoses. Includes one-time 4-hour training and 1-2 brief conversations with mentees on an as needed basis.
Teen Advisory Committee: Patients/siblings group. Members may join during freshman or sophomore year in high school. Minimum commitment is one full school year of monthly meetings (11 meetings)
Latino family engagement: contact Cecilia Matos at (617) 355-3196 or cecilia.matos@childrens.harvard.edu
Volunteer Services Program: Visit the Volunteer Services webpage at: www.childrenshospital.org/ways-to-help/volunteerservices
Cook a meal for families: contact FamilyHousing@childrens.harvard.edu
Get involved with the Boston Children's Hospital Trust: See Ways to Give Back to Boston Children's Hospital guide for contact information
Tell your story: Email marketing at marketing@childrens.harvard.edu
Join the Child Advocacy Network (CAN): contact Government Relations at kathryn.audette@childrens.harvard.edu or (617) 919 3062
Other
Please note that Family Partnerships recruitment is ongoing. Different opportunities will arise at different times for patient and family involvement.
Please share with us some information about why you would like to get involved with Family Partnerships.
If Other, please specify: If you chose 'Other,' please indicate how you would like to participate.
Area(s) of Interest Building and Facilities
Clinical Education and Training (Bringing the patient/family perspective to Boston Children's Hospital employees)
Family Education (Improving written or video-based education about a wide variety of topics to patients and families)
Patient and Family Experience (May be inpatient or outpatient)
Hospital Policies and Processes
Research
Technology (How clinicians / the hospital use technology to connect with patients and families)
International Patient and Family Experience
Other
Please choose area(s) of interest.
If Other, please specify: If you chose 'Other,' please indicate other area(s) of interest.
Profession / Industry Please indicate your profession.
Do you speak any languages in addition to English? Yes
No
If 'yes' please list the languages you speak Skill(s) Marketing
Public Speaking
Reviewing/Editing Materials
Strategic Planning
Technology
Writing
Other
Please indicate skill(s) you'd like to share.
If Other, please specify: If you chose 'Other,' please indicate other skill(s) you'd like to share.
Please share some of your hobbies and interests outside of your profession. (This helps us to know you better)
Does your schedule allow you to: Attend meetings in person during regular business hours? (Mon-Fri 8:30am - 5pm)
Attend meetings in the evening? (5:30pm or later)
Participate in meetings, conference calls, interviews over the phone during regular business hours?
Participate in providing feedback online (Through our Virtual Advisory Council)
Complete surveys online
Please mark all that apply
If you are able to attend meetings during business hours, how often are you able to do so? Regularly (weekly or bi-weekly)
Once in a while (once a month or less)
If you are able to attend meetings in the evening (5:30pm or later), how often can you do so? Regularly (weekly or bi-weekly)
Once in a while (once a month or less)
Working...