2022 Miracle Child Nomination Form

The Erlanger Health System Foundation and the Children’s Miracle Network Hospitals team are looking for four outstanding patients to become 2022 Miracle Children. The CMN Hospitals team, which raises more than $800,000 each year for Children’s, plans to feature the patients in 2022 CMN Hospitals campaign material and a Miracle Children video. These families will also speak at corporate and donor fundraising events throughout the year.

Please keep the following considerations in mind when making your nominations—the child and family should:

Be flexible and dependable
Have phone/email resources to be contacted
Be well-spoken and willing to share their child’s story in front of various groups of people, including the media (radio, TV, web, etc.)
Have reliable transportation to attend events; families are invited to attend approximately eight events annually within the Chattanooga region.
Have received the majority of their care at Children’s within the last year.
Be comfortable with photos of their child being shared on Erlanger’s and our Corporate Partner’s social media accounts for CMNH and Erlanger Corporate Partners related events

Please note: Nomination does not guarantee selection. Only 3–4 patients will be selected.

Name of child being nominated

First Name

Last Name

Your Name

First Name

Last Name

Your relationship to the patient

Patient's parent/legal guardian's name

First Name

Last Name

Patient's parent/legal guardian's email

Patient's parent/legal guardian's phone

(###)

###

####

Patient's Date of Birth

YYYY

Age when patient began treatment at Children's Hospital

Patient's Sex

Male

Female

Do not wish to disclose

Patient's Ethnicity

Child's primary language?

Are the parents fluent in English?

Yes

If parents are not fluent in English, please provide name(s) of someone who can speak on their behalf.

Does the patient have siblings? If so, what are their names and ages?

Does the patient have any special hobbies or talents? If so, what are they?

Patient's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What initially brought the patient to Children’s?

What was the diagnosis?

Please share the patient’s story of his/her time at Children’s:

Please list any instrumental staff members and department(s) involved in the patient’s care:

What has been the hardest part of the patient’s medical journey?

Why do you think this patient should be a 2020 Miracle Child?

Permission for Use of Personal Image and Information

The child's parent/legal guardian must agree to the following Children’s Hospital at Erlanger consent form prior to clicking “Submit” below. Please read this consent document carefully before agreeing to its terms. It contains information related to the use of your story, photographs and other information you provide to Children's. By selecting "I Agree," you acknowledge that you understand and agree to be bound by the terms. By agreeing below, I, as the patient's legal guardian/parent, hereby authorize Erlanger, its affiliated companies, and/or their legally authorized representatives to acquire and utilize the patient's name, image, written expression, or other representation. I understand that the patient may be identified by name in printed, Internet, or broadcast information that might accompany the testimonial, interview, photograph, or image. I understand that by submitting this release, the testimonial, interview, photograph or image becomes the property of Erlanger, the news media, and/or external publications. I attest that information provided pursuant to this authorization is, to the best of my knowledge, complete and accurate as of the date of this release. If there is any special limitation as to the uses authorized by this release, or if there are conditions as to time, remuneration, media, or other circumstance, please submit these requirements in writing to your Erlanger contact. This Release covers all usages and releases Erlanger, its directors, members, trustees, officers, employees, and agents and my physician(s) and any other person participating in my care from all claims, demands, causes of action and suits, including but not limited to claims for invasion of privacy, defamation, breach of contract, or other breach of duty arising out of, or in connection with, the use of this testimonial, interview, photograph, film, or video. I have read, or have had read to me, the above statements, and understand them as they apply to me. I further understand that I may revoke this authorization at any time, except to the extent that action has already been taken in accord with this authorization. In order to revoke an authorization, a written document stating the intent of the patient/visitor/employee to revoke such authorization must be either presented in person to or delivered by certified mail to the Chief Privacy Officer of Erlanger Health System. This document must contain the signature of the patient or patient’s legal representative, and that signature must be formally certified by a Notary Public. By agreeing to these terms and conditions, I certify that I am the named individual, and that I am an adult and legally competent to execute this Release, or I am the duly authorized legal guardian/representative/agent of the named individual, and I am empowered to execute this Release.

I Agree

2022 Miracle Child Nomination Form

Your gift. Advancing health.