Become a Patient Champion :: Nationwide Children's Hospital

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Become a Patient Champion

Patient Champions are individuals treated at Nationwide Children's Hospital in any department. Whether it’s participating in fundraising events, sharing your story through the various hospital media outlets or getting involved with our hospital programs- our Patient Champions are the motivation behind the work that we do. 

We invite you to share your story with us.
Your Contact Information
First Name *
Last Name *
Email Address *
Phone Number *
Relationship to Patient *
Parent or Guardian
Nationwide Children's Employee
Teacher or Family Friend
Patient Information
Patient Champion's Name *
Patient Champion's Birthday
Address 1
Address 2
Zip Code
Parent/Guardian (1)
Parent/Guardian (2)
Name of Patient Champion's Primary Nationwide Children's Physician
Diagnosis (if applicable)
Please list any health needs that may require special attention (i.e. ventilator, allergies, etc.)
Your story (Max 600 characters) *
What does Nationwide Children's mean to you? (Max 600 characters)
Tell us about your Patient Champion's likes, dislikes, hobbies and interests
Would you like us to share your story specifically with anyone from your hospital care team? If yes, who?
We share Patient Champion stories throughout the year in a variety of ways including newsletters, social media, events and more. Please select the areas that interest you to represent all the patients treated at Nationwide Children's from the following:
Running Events (The Nationwide Children's Hospital Columbus Marathon, other local 5Ks)
Golf Events (The Memorial tournament presented by Nationwide, Nationwide Children's Hospital Championship, other local golf outings)
Telethons and Radiothons
Other Events (Dance Marathons, other local fundraising events or campaigns)
Printed Stories in Newsletters, Mailings and Social Media
I do not have a preference
Please select the ways you are comfortable sharing your story
Television interview
Radio interview
Hospital publications
Hospital website/social media
Event attendance
All news media
Do you have a photo to share?
- Please send a photo to and reference "Patient Champion" name in the subject line.
How were you referred to the application? (i.e. Kinder Key, Hospital Staff, Facebook, etc.)
I have read and agree to the Patient Champion Expectations and to the Terms and Conditions below. *
I am at least 18 years old or the legal guardian of the child/patient for which I am submitting the story *

*Terms and Conditions

I understand and agree to allow Nationwide Children's Hospital to use the information, photo and or video, I am submitting.

I understand that my information may be used for marketing, publicizing, or otherwise promoting Nationwide Children's Hospital mission and that my information may be disseminated in any medium without geographic or time restriction.

I authorize the release of any information including health information contained in this submission and authorize the staff of Nationwide Children's Hospital to discuss this information with physicians and other staff, as necessary to verify the accuracy of the information.

I waive and release Nationwide Children's Hospital from any and all claims that I may have against Nationwide Children's Hospital or its officers, directors, employees, agents, or affiliates arising out of its use or dissemination this information.

I also waive any right to royalties or other compensation for Nationwide Children's use and dissemination of this information.

I assign all rights, including copyright, to the information to Nationwide Children's Hospital.

I represent and warrant that I have the authority to provide the information to Nationwide Children's Hospital and that no one else owns or has superior rights to this information.

I have read, fully understand, and voluntarily agree to be legally bound by this waiver, release, and authorization form.

I understand and agree that I may not use this site to conduct any activity that is illegal or that violates the rights or others. I represent and warrant that all information submitted is truthful and accurate.

Nationwide Children's Hospital
700 Children's Drive Columbus, Ohio 43205 614.722.2000