The Kids' Hospital Network Permission Slip to submit material -stories, pictures, etc.
Please Print this form out and snail mail or fax it to us
Please Clearly Print the Information
Individual work ____________
Class Project _____________
Hospital Project ___________
Name: ________________________________________ Birth Date: _______________________
Address: ______________________________________ Town/City: ________________________
State/Providence: _______________________________ Zip Code: _______________________
Telephone number or TTY: ( ) _______ - _________ Male or Female: (circle one)
Webpage: ______________________________________ Email: __________________________
School Name: _________________________________ Grade: __________________________
Address: _______________________________________ Town/City: _______________________
State/Providence: _________________________________ Zip Code: _______________________
Teacher/Child Life Specialist's Name: _________________________________________________
Email: _____________________________________ Phone: ________________________
Confidential: (Optional) If you have an illness or a challenge you may share it with us
________________________________________________________________________________
Languages you speak or write? ______________________________________________________
School Activities you are involved with? ________________________________________________
Community Volunteering? __________________________________________________________
Hobbies and Interests _____________________________________________________________
What computer skills do you have? ___________________________________________________
_________________________________________________________________________________
Student Signature Date
Parents and Students must read the online Disclaimer
________________________________________________________________________________
Parent/Guardian Signature (students under 18 must have permission to participate) Date
