Kick Off Kid - Child Questionnaire

About Your Child
What does your child like to do or play?
(i.e. read comics, play soccer, paint, etc.)
Any favorites you want to share with us about your child?
(i.e. color, locations, travel, etc.)
Is there anyone your child would like to give a shout out to? (i.e. family members, teacher, etc.)

Parent / Caregiver Information
Parent/Caregiver Full Name

First NameLast Name
Secondary Parent/Caregiver Full Name (if applicable)

First NameLast Name
Yes, I will be attending.Yes, both of us will be attending.We will be unable to attend.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What was the most important memory you have of your LRH NICU/hospital stay?

Photo Consent
YesNo
Haven't submitted a Photo Consent form? Please visit myLRH.org/PhotoConsent to complete and submit the form.
Should be Empty:

Child's Info