Become a Patient Champion :: Nationwide Children's Hospital

Become a Patient Champion

We invite you to share your story with us.

If you are interested in becoming a Marathon Patient Champion, please complete this form.

Please share your story
Your Contact Information
First Name *
Last Name *
Email Address *
Phone Number *
Relation to Patient *
Patient Family Information
Patient Champion's Name *
Address
City
State
Zip Code
Patient Story
Please select which best represents you:
Name of Patient Champion's Primary Care 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 Children's mean to you? (Max 600 characters) *
Would you like us to share your story specifically with anyone from your hospital care team of your story? If yes, who?
Do you have a photo to share?
Please send a photo to ChildrensChampions@NationwideChildrens.org and reference "Patient Champion" name in the subject line.
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 maybe used for marketing, publicizing, or otherwise promoting Nationwide Children's Hospital mission and that my information maybe 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