General Information Location of Medical FacilityPlease select... United States Canada China Israel Medical Facility Name Department/Unit/Clinic Contact Person: First Name Contact Person: Last Name Contact Person Title Contact Email Address Street Address to receive donations (i.e. 100 Sunshine Lane, Room 604) Any additional directions (i.e. attention child life, room 402) City StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Phone Extension Have you worked with Project Sunshine prior to working at your current medical facility?YesNo We want to be mindful of your medical facility and departmental restrictions so please indicate if there are any specific restrictions we should be aware of. Please note that all of our donation/activities are latex free. Patient Demographic Information Number of children receiving care on your unit/clinic For each age group below, please list the average number of pediatric patients seen daily in YOUR unit/clinic. Please do not leave blank. Mark zero as it applies. 0-2 years old 3-6 years old 7-11 years old 12-14 years old 15-21 years old Which of the following conditions affect a significant percentage of patients in YOUR unit/clinic? Select all that apply.ADHDAsthmaAutismCancerCerebral PalsyChronic illnessDevelopmental disabilitiesDiabetesDuchenne's Muscular DystrophyHemophiliaLimited mobilityMental healthMultiple SclerosisNeonatal Abstinence SyndromeObesitySpinal Muscular AtrophyStroke/Blood clotsOtherNot applicable We aren’t able to translate our materials into all languages, but for future reference, please check the 3 most frequently spoken languages by the patients in your unit/clinic.American Sign LanguageArabicBengaliCantoneseFrenchGermanGreekHebrewHindiHmongItalianJapaneseJavaneseKoreanMandarinPolishPortuguesePunjabiRussianSpanishUrduVietnameseNot applicable What percentage of the pediatric patient population in your unit/clinic would you consider to be underserved and/or have limited access to resources? Sending Sunshine Items Please note that the below requests are subject to the availability of Project Sunshine’s materials based on the number of hospital partners at any given time. We will try to accommodate your program and shipping requests. Please check off any of the Sending Sunshine items you are interested in receiving. PuppetCrownSuperheroBasketballSTEMCaregiverBuildingScrapbookSensoryMandalaSurgi Dolls Project Sunshine recognizes the storage challenges our medical partners face so please indicate the number of items you would like to receive in each shipment. The exact number may vary depending on availability.Please select... Up to 100 Up to 200 Up to 300 Up to 400 Up to 500 n/a (I do not wish to receive Sending Sunshine items) For more information about these kits, you can view them in more detail here. Would you accept Surgi Dolls that are asymmetrical, or sewn by less experienced volunteers?YesNo If yes, is there a limit to how many you can accept? If we are able to provide the above services, please specify the names of all the units/clinics to which you plan to distribute them. (Alternatively you can have each unit within your facility fill out separate applications.) Project Sunshine In-hospital Volunteer Programming Please check any in-hospital volunteer programs that interest you. Please keep in mind the below programs are subject to availability of volunteer groups in your area. Please select... Arts and Crafts Caregiver Wellness Party Time Making the Band I do not wish to receive in-hospital volunteer programming Use Ctrl button to select multiple programs. For more information about our in-hospital volunteer programs, you can view them in more detail here. Project Sunshine also partners with corporations to support special events. Would your facility be interested in volunteers/support for special events?YesNoMaybe How many volunteers can you accommodate for a special event? Marketing and Social Media Consent Does your facility allow third-party consented photos to be taken at a program?YesNoUnsure If known, please provide the best contact at the medical facility for questions related to volunteer management processes (Name, Title, Department, Email, and Phone Number). If known, please provide the best contact at the medical facility for questions related to marketing, communications and/or social media consent (Name, Title, Department, Email, and Phone Number). If known, please provide the best contact at the medical facility for questions related to development and/or external relations (Name, Title, Department, Email, and Phone Number). Additional Comments Please include any comments or questions you have for Project Sunshine. Contact Information
