2017 - Kid Ambassador Program

We’re once again doing the Kid Ambassador program to honor pediatric patients at the UI Stead Family Children’s Hospital and celebrate their inspirational stories!

Do you know a child with a remarkable story?  Nominate them below to become a 2017 Kid Ambassador!  The program is open to any UI Stead Family Children’s Hospital patient from Muscatine or the surrounding communities under the age of 18.  Only parents or legal guardians may nominate their child.  To submit multiple Kid Ambassador nominations from one family, please submit the nomination form separately for each child.

Nominations are due by April 15th, 2017.

2017 Kid Ambassador Nomination

    My information

  • Child's Information

  • Your Experience

  • Participation

  • I hereby give consent for my child to participate in a promotional story, program, advertisement and/or image (photo or video) made for Kolors for Kids in which my child/family will be interviewed and quoted by name. I understand that this story, program, advertisement and/or image (photo or video) will appear in the public media, including print, internet, and/or broadcast media for a period of up to six (6) years. I understand that pictures will be taken of my child and family. I understand that this story, program, advertisement and/or image (photo and/or video) may be used more than once for promotional purposes by Kolors 4 Kids. I have been informed that once information is disclosed it may no longer be protected by federal privacy regulations. I have been informed that this authorization is voluntary and may be revoked at any time by providing notice in writing to the following address: Kolors 4 Kids, 215 E 2nd St., Muscatine, IA 52761. This revocation will not affect any actions taken before receipt of the written notification.
 

Verification

 

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