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
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?
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:
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:
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:
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:
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:
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
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?
If 'yes' please list the languages you speak Skill(s)
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:
Please mark all that apply
If you are able to attend meetings during business hours, how often are you able to do so?
If you are able to attend meetings in the evening (5:30pm or later), how often can you do so?
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