Become a Member 

• * First Name
  
• M.I.
  
• * Last Name
  
• * Age
  
• * Address
  
• * City
  
• * State
  Please choose... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• * Zip Code
  
• * Phone
  
• Fax
  
• * E-mail
  
• * Confirm E-mail
  

• Child's Name
  
• Child's Age
  
• Your Relationship to Child
  
• What language does the family speak at home?
  
• Do you speak more than one language? Yes No
• Do you have other children who visit your child at the hospital? Yes No
• If yes, what are their ages?
  
• Was your child born at the hospital? Yes No
• How many times has your child visited the hospital? (Approximate)
  
• How many years has your child been visiting the hospital?
  
• Has your child ever been admitted to the hospital for an overnight stay? Yes No
• If yes, approximately how many times?
  
• Approximate length of stay [or longest stay]
  
• Please briefly describe your child's medical story.
  
• Please check the different departments that your child has visited at the hospital (please check all that apply).
• 
  Cardiac
  Cardiology
  GI/Liver
  Medicine
  Burn
• Neonatology
  Neurology
  Oncology
  Orthopedic
  
• Psychiatry
  Renal (Kidney related)
  Surgery
  Transplant
  
• Other (Please Indicate)
• What is one of your child’s best hospital stories?
• What is one of your child’s worst hospital stories?
• If you were a council member, what changes would you make to fix this problem?
• Please tell us why you think parents should have a bigger role in decision-making at the hospital.
• Please tell us anything else about your family that would add to the diversity of the council (religion, race, culture, family structure, etc)
• How did you hear about us?
• Flyer or Brochure
• Physician
• Hospital staff member
• Other

Hospital Recommendation

We would like to ask a NYP hospital staff member to support your application. Please give us the name of a doctor, nurse, child-life specialist, social worker, or anyone else who knows you.

• Name of Staff Member:
• Please note: Council Members are considered volunteers of the hospital. If you are chosen to be a Council Member you will need a medical screening and a background check; both will be done by the hospital’s Volunteer Services Department.
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