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Enrolled Child Information
Please Select Your Chapter
*
Please select
Central Carolinas Chapter
Central Ohio Chapter
Michigan Chapter
Mid-Atlantic Chapter
Indiana Chapter
National Chapter
Northern Ohio Chapter
Southwest Ohio Chapter
Enrolled Child's Name
*
First
Last
Email
Have you moved recently?
*
Yes
No
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Hidden
Section Break
Does your child require wheel chair access?
*
Yes
No
Does your family have a nurse/aid?
*
Yes
No
My child has (check all that apply):
Select All
Non-verbal
Sensory Disorder
Feeding Tube
Tracheostomy
Ventilator
Home Oxygen
Home Bipap/Cpap
With how many doctors or specialists does your child routinely have appointments (Besides Pediatrician/Primary Care Physician, Eye Doctor, Dentist)?
*
Is your child seen by a complex care unit, palliative care, or hospice?
*
Yes
No
Hospital Information
Hospital Providing Care
*
Choose Hospital
AdventHealth For Children
Advocate Children's Hospital
Akron Children's Hospital
American Family Children's Hospital
AnMed Health Women's and Children's Hospital
Ann and Robert H. Lurie Children's Hospital of Chicago
Arkansas Children's Hospital
Arnold Palmer Hospital for Children
Ascension St. John Children's Hospital
Barbara Bush Children's Hospital
Baystate Children's Hospital
Beacon Children's Hospital
Blank Children's Hospital
Blythedale Children's Hospital
Boston Children's Hospital
Bradley Hospital (Children's Psychiatric)
Brenner Children's Hospital
Bristol Myers Squibb Children's Hospital
Bronson Methodist Children's Health
C.S. Mott Children's Hospital
CAMC Women and Children's Hospital
Cardinal Glennon Children's Hospital
Cardon Children's Medical Center
Carilion Clinic Children's Hospital
Children’s Hospital at Erlanger
Children's Center at Sutter Medical Center
Children's Healthcare of Atlanta
Children's Hospital & Medical Center
Children's Hospital at Dartmouth (CHaD)
Children's Hospital at Montefiore
Children's Hospital Colorado
Children's Hospital Los Angeles
Children's Hospital of Georgia
Children's Hospital of Michigan
Children's Hospital of Nevada
Children's Hospital of New Jersey
Children's Hospital of New Orleans
Children's Hospital of Orange County
Children's Hospital of Philadelphia
Children's Hospital of Richmond at VCU
Children's Hospital of San Antonio
Children's Hospital of The King's Daughters
Children's Hospital of Wisconsin
Children's Hospital of Wisconsin-Fox Valley
Children's Hospitals and Clinics of Minnesota
Children's Medical Center Dallas
Children's Memorial Hermann Hospital
Children's Mercy Hospital
Children's Mercy Hospital Kansas
Children's National Medical Center
Children's of Alabama
Children's of Mississippi
Children's Regional Hospital at Cooper
Children's Specialized Hospital
Cincinnati Children's Hospital Medical Center
Cleveland Clinic Children's Hospital
Connecticut Children's Medical Center
Cook Children's Healthcare System
Covenant Children's Hospital
Dayton Children's Hospital
Dell Children's Medical Center of Central Texas
Doernbecher Children's Hospital
Driscoll Children's Hospital
Duke Children's Hospital
Dwaine & Cynthia Willett Children’s Hospital of Savannah
East Tennessee Children's Hospital
Edinburg Children's Hospital
El Paso Children's Hospital
Essentia Health-St. Mary’s Children’s Hospital
Floating Hospital for Children
Franciscan Hospital for Children
Gillette Children's Specialty Healthcare
Golisano Children's Hospital
Golisano Children's Hospital of Southwest Florida
Goryeb Children's Hospital
Greenville South Carolina Children's Hospital
Hasbro Children's Hospital
Hassenfeld Children's Hospital
Helen DeVos Children's Hospital
Hemby Children's Hospital
Holtz Children's Hospital
Huntsville Hospital for Women and Children
Hurley Children's Hospital
Indiana University Hospital
INOVA Children's Hospital
Janet Weis Children's Hospital
Jeff Gordon's Children's Hospital
Joe DiMaggio Children’s Hospital
John R. Oishei Children’s Hospital
John Sealy Children's Hospital
Johns Hopkins All Children's Hospital
Johns Hopkins Children's Center
Joseph M. Sanzari Children's Hospital
K. Hovnanian Children's Hospital
Kapi'olani Medical Center for Women & Children
Kennedy Krieger Institute
Komansky Center for Children's Health
Kravis Children's Hospital
La Rabida Children's Hospital
Lauren Small Children's Center at Bakersfield Memorial Hospital
Le Bonheur Children's Medical Center
Lehigh Valley Reilly Children’s Hospital
Levine Children's Hospital
Loma Linda University Children's Hospital
Lucile Packard Children's Hospital at Stanford
Lutheran's Children Hospital
M Health Fairview Masonic Children's Hospital
Maria Fareri Children's Hospital
Mary Bridge Children's Hospital
MassGeneral Hospital for Children
Mattel Children's Hospital UCLA
Maynard Children's Hospital
Mayo Clinic – Eugenio Litta Children's Hospital
Medical City Children's Hospital
Memorial Hospital for Children
Memorial Sloan Kettering Children’s Cancer Center
Mercy Health — Children’s Hospital
Mercy Kids Children's Hospital St. Louis
Methodist Children's Hospital
Miller Children's Hospital
Monroe Carell Jr. Children's Hospital at Vanderbilt
Montana Children's Medical Center
Morgan Stanley Children's Hospital
Mt. Washington Pediatric Hospital
MUSC Shawn Jenkins Children's Hospital
Nationwide Children's Hospital
Nemours Alfred I. duPont Hospital for Children
Nemours Children's Hospital
Nicklaus Children's Hospital
Niswonger Children's Hospital
North Shore Children's Hospital
Norton Children's Hospital
Ochsner Hospital for Children
Our Lady of the Lake Children's Hospital
Palm Beach Children's Hospital
Palmetto Health Children's Hospital
Parkview Hospital
Penn State Children's Hospital
Peyton Manning Children's Hospital
Phoenix Children's Hospital
Primary Children's Hospital
Providence Memorial Children's Hospital
Puerto Rico Children's Hospital
Rady Children's Hospital
Rainbow Babies & Children's Hospital
Randall Children's Hospital at Legacy Emanuel
Ranken Jordan Pediatric Bridge Hospital
Renown Children's Hospital
Riley Hospital for Children
Rocky Mountain Hospital for Children
Rush University Children's Hospital
Sacred Heart Children's Hospital
Saint Joseph's Children's Hospital
Saint Mary's Children's Hospital
Salah Foundation Children’s Hospital
San Jorge Children's Hospital
Sanford Health Children's Hospital
Scott & White Memorial Hospital Children's Hospital
Seattle Children's
Shriners Hospital for Children
Shriners Hospital for Children Los Angeles and Sacramento
St. Christopher's Hospital for Children
St. John's Children's Hospital
St. Joseph's Children's Hospital
St. Jude Children's Research Hospital
St. Louis Children's Hospital
St. Luke's Children's Hospital
St. Mary's Hospital for Children
Steven and Alexandra Cohen Children's Medical Center of New York
Stony Brook Children's Hospital
Studer Family Children's Hospital
Sunrise Children's Hospital
Texas Children's Hospital
Texas Scottish Rite Hospital for Children
The Children’s Hospital at Saint Peter's University Hospital
The Children's Hospital at HCMC
The Children's Hospital at Providence
The Children's Hospital at Saint Francis
The Children's Hospital at The Medical Center of Central Georgia
The Children's Hospital of Illinois
The Children's Hospital of Oklahoma
The Herman & Walter Samuelson Children's Hospital at Sinai
Toledo Children's Hospital
UC Davis Medical Center
UCSF Benioff Children's Hospital
UCSF Benioff Children's Hospital Oakland
UF Health Shands Children's Hospital
UMass Memorial Children's Medical Center
UNC Children's Hospital
University Hospital Pediatrics
University of Chicago Comer Children's Hospital
University of Iowa Stead Family Children's Hospital
University of Kentucky Children's Hospital
University of Maryland Children's Hospital
University of Missouri Women's and Children's Hospital
University of Vermont Children's Hospital
University of Virginia Children's Hospital
University Pediatric Hospital (Medical Science Campus)
Unterberg Children Hospital
UPMC Children's Hospital of Pittsburgh
Upstate Golisano Children's Hospital
USA Children's and Women's Hospital
Valley Children's Hospital
West Virginia University Children's Hospital
Wolfson Children's Hospital
Women & Infants Hospital of Rhode Island
Yale-New Haven Children's Hospital
Other Please List Below
Other Hospital or Medical Center
*
Personal Information
We collect this data for grant applications that will help provide more Adventures and support for our families. Grants may ask for demographic information such as income, race, religion, school district, etc.
Race of enrolled child
*
White, Non-Hispanic
African American
Latino
American Indian/Alaska Native
Asian
Pacific Islander
Middle Eastern
Other (specify below)
I'd prefer not to answer
Other (race of enrolled child):
*
Annual Household Income
*
Select an answer
0-30K
31K-55K
56K-75K
76K-100K
101K-150K
150K+
I'd prefer not to answer
Name of School enrolled child attends:
Name of health insurance carrier:
*
Please Make A Selection
Anthem
Aetna
BCBS
CareSource
Cigna
Humana
Medicare/Medicaid
UHC
Other (specify below)
I'd prefer not answer
Other (health insurance carrier):
*
Do you have regular access to internet?
*
Select an Option
Yes
No
Employer Information
During our Annual Corporate Fundraising Campaign we are routinely asked by corporations if any of our parents work for that particular corporation. Corporations are more likely to support a cause if they know that it will benefit their employees.
Employer for Mother/Guardian #1
Employer for Father/Guardian #2
How did you hear about A Kid Again?
*
Facebook
Twitter
Other Social Media
Another Family
School
Internet
TV/Radio/News
Hospital/Medical facility
Other (specify below)
Other (how did you hear about us):
*
Can any immediate family members be classified in one of these categories?
Adopted Child(ren)
Blended Family
Foster Family
Guardianship
LGBTQ+
Military - Currently Enlisted
Military - Veteran
Additional languages used in the home
Arabic
French
Mandarin
Sign Language
Somali
Spanish
Other (specify below)
Other (language)
*
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