Summer Scamper Patient Hero Program

1. Please share a brief (four- or five-sentence) summary of the Patient Heroes' connection to our hospital: *This question is required.

2. Are there doctors, nurses, specialists, or other staff members who made a positive impact on your family’s experience at our hospital? *This question is required.

3. Would you (and/or the Patient Hero(es) if appropriate) be willing to share your family’s story with our supporters in the form of a very brief speech at a corporate sponsor’s office or other gathering? Please note: Public speaking is not required, but a nice way for our community to meet the Patient Heroes prior to Summer Scamper. *This question is required.

4. If yes, do you have any specific requests for giving a speech? (e.g. audience size limit, no weekdays, etc.)

5. What is the Patient Hero's preferred t-shirt size?

6. Please share the names of parents and names and ages of all siblings in the Patient Hero’s family:

Patient Hero #WhyWeScamper Video

Summer Scamper Patient Heroes are #WhyWeScamper. Help us feature your Patient Hero(es) in a compilation video we’re putting together honoring these special kiddos. Please share fun facts and photos about your Patient Hero below.

7. A favorite activity or hobby: *This question is required.

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8. A favorite memory: *This question is required.

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9. A favorite care provider:

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10. A favorite personality trait: *This question is required.

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*Please note: The file size limit for each photo is 2 MB. If you have more photos to share, or they are too large, please email them directly to Megan Alpers at Megan.Alpers@lpfch.org. Thank you!