Share Your Story

Share your story

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Stollery kid details

Name*

First Last

Birthdate*

MM slash DD slash YYYY

Pronouns*

she/her | he/him | they/them | other

Medical condition(s)/diagnosis*

Primary Stollery doctor(s)

Approximate time spent in hospital (days, weeks, months, etc.)

Surgeries/procedures*

Feel free to include key/major surgeries or procedures that your Stollery kid has experienced.

Interests (sports, music, cars, etc.)*

Has your child received any mental health care at the Stollery?*

Yes

No

Are you comfortable sharing your child's mental health story?

Yes

No

Please summarize your child's mental health story

Are there any other Stollery kids in your family?*

Yes

No

Additional Stollery kids (if applicable)

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Stollery story

Briefly share with us what brought your family to the Stollery. Please include how your Stollery kid(s) is doing today.

Story description (maximum 500 characters)*

Photos of your Stollery kid(s) and/or artwork

or drop files here Select files

Size: 20 MB.

Upload 1-4 photos of your child to be added to your family's Squad file. If you are supplying artwork through Child Life, please upload a picture of your child's masterpiece.

Is your family documenting your Stollery story online?

Personal blog, Facebook page, Instagram account, etc.

Yes

No

Where can we follow along?

Please include the URL to any applicable websites or social media platforms.

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Primary guardian details

Name*

First Last

Relationship*

Email*

Phone*

Workplace (if you work outside your home)

Address*

Street Address City Province Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Family details

Additional Guardian (if applicable)

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Siblings (if applicable)

Name	Actions
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Add sibling

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Please include all siblings not identified as having their own Stollery story above.

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Finalize submission

What connections do you have with the Stollery? (Please check all that apply)

My kid(s) are Stollery Superstars (youth fundraisers)

I'm a donor

I personally fundraise for the Stollery

I'm a volunteer (Stollery Women's Network, general volunteer)

I'm a Stollery Children's Hospital staff member

I work for a company that supports the Foundation:

Email consent*

By clicking this box, I give my expressed consent to receive electronic news and information from the Stollery Children’s Hospital Foundation.

Authorization form

In an effort to reduce touchpoints and streamline our authorization process, we’re hoping to complete your waiver form in advance.

Authorization is hereby given to the Stollery Children’s Hospital Foundation to take still photographs, moving pictures, television or sound recordings of:*

Please include the names of all immediate family members, including yourself, your Stollery kid(s), partner, siblings, etc.

I agree photos and/or artwork provided to and/or captured by the Stollery Children’s Hospital Foundation may be used now or in the future for the purpose of (please check all that apply):*

Website and social media promotion – on the Foundation website(s) and/or social media platforms (including but not limited to: Twitter, Facebook, Instagram, YouTube, stollerykids.com)

Partner/affiliate publication/promotion – can be shared with our affiliates such as the Stollery Children’s Hospital, Alberta Health Services, Women and Children’s Health Research Institute, the University of Alberta, Canada’s Children’s Hospital Foundations

All – can be used for Foundation promotional purposes including, but not limited to website/social media promotion, shared with affiliates and mass media opportunities.

None – I do not want my photos shared in any way without my knowledge.

Should a large-scale/mass media marketing opportunity arise, every attempt will be made to gain permission and notify you prior to sharing your photo(s).

Signature*

Our commitment to your privacy

The Stollery Children’s Hospital Foundation respects your privacy. We do not rent, sell, or trade our contact lists. Personal information collected will be used to keep you informed of our charitable work, funding needs and opportunities to volunteer or give.

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