Hospital Healthcare Professionals

Hospital Healthcare Professionals Application Form

Name

Email Address

Hospital Name

Hospital Address

Hospital Phone Number

Your Position

How did you hear about Dec My Room?

How many pediatric hospitals in the area (within a 10 mile radius) are affiliated with your hospital?

How many pediatric patients are admitted for 3 weeks or longer?

What therapeutic areas does your hospital specialize in?

BMT
Hem/Onc
Solid Organ Transplant
Children’s Cancers
Burn Unit
Long Term Physical Rehabilitation
Other

How many Child Life Specialists work at your hospital?

How many CLS work in your local hospital system?

Do you work with a group of volunteers?

Does the hospital have an established foundation that can provide funding for hospital decorations to improve the stays for long term pediatric patients?

Comments or Other Information