Beads of Courage Flagship Program Ambassador Updates

We know that there is constant change and movement in a fast-paced hospital setting. Please take a few minutes to help the Program Team at Beads of Courage keep our records up to date as well as for us to best assist you.

Please provide contacts in all Beads of Courage Program areas. If you are not licensed to use certain programs, please leave those areas blank. This will allow us to continue to support your team can as well as keep you up to date on anything in regard to Beads of Courage.

Please email the program team at programs@beadsofcourage.org at anytime for assistance.

Date Date / MM / DD YYYY
Name (of person completing this form): Name (of person completing this form): First Last
Title & Department (of person completing this form)
Email (of person completing this form):
Phone (of person completing this form): Phone (of person completing this form): - ### - ### ####
Hospital/Organization Name:

Please provide the official and legal name of the hospital/organization (i.e./ Name used in legal documents; not nicknames or acronyms)
Hospital/Organization Mailing Address Hospital/Organization Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Beads of Courage Hematology/Oncology Ambassador information
Hem/Onc Beads of Courage Ambassador Hem/Onc Beads of Courage Ambassador First Last
Please complete if you are licensed to use the Beads of Courage Hem/Onc Flagship Program.

If there is more than one, please provide lead ambassador information and include additional names and contacts in the comment section.
Hem/Onc BOC Ambassador Title/Department:
Hem/Onc BOC Ambassador Phone: Hem/Onc BOC Ambassador Phone: - ### - ### ####
Hem/Onc BOC Ambassador Email
Area descriptions of where BOC program is being implemented.

Please help us to better understand where the BOC program is being used at your facility. We appreciate as much detail as possible.

For example, 30-bed inpatient unit, outpatient clinic seeing 60-70 patients per week, small 10-bed pediatric unit in an adult hospital, etc...

If the program is being used in satellite buildings with differing address from the main facility, please indicate where/address.
Additional Hem/Onc Ambassador contacts or comments:

Please add any additional Hem/Onc Ambassadors here including name, email, and phone number.
Beads of Courage Cardiac Ambassador Information
Area descriptions of where BOC program is being implemented.

Please help us to better understand where the BOC program is being used at your facility. We appreciate as much detail as possible.

For example, 30-bed inpatient unit, outpatient clinic seeing 60-70 patients per week, small 10-bed pediatric unit in an adult hospital, etc...
Cardiac Beads of Courage Ambassador Cardiac Beads of Courage Ambassador First Last
Please complete if you are licensed to use the Beads of Courage Cardiac Flagship Program.

If there is more than one, please provide lead ambassador information and include additional names and contacts in the comment section.
Cardiac Beads of Courage Ambassador Cardiac Beads of Courage Ambassador First Last
Cardiac BOC Ambassador Title/Department:
Cardiac BOC Ambassador Phone: Cardiac BOC Ambassador Phone: - ### - ### ####
Cardiac BOC Ambassador Email:
Area descriptions of where BOC program is being implemented.

Please help us to better understand where the BOC program is being used at your facility. We appreciate as much detail as possible.

For example, 30-bed inpatient unit, outpatient clinic seeing 60-70 patients per week, small 10-bed pediatric unit in an adult hospital, etc...

If the program is being used in satellite buildings with differing address from the main facility, please indicate where/address.
Additional Cardiac Ambassador contacts or comments:

Please add any additional Cardiac Ambassadors here including name, email, and phone number.
Beads of Courage NICU Ambassador Information:
NICU Beads of Courage Ambassador NICU Beads of Courage Ambassador First Last
Please complete if you are licensed to use the Beads of Courage NICU Flagship Program.

If there is more than one, please provide lead ambassador information and include additional names and contacts in the comment section.
NICU BOC Ambassador Title/Department:
NICU BOC Ambassador Phone: NICU BOC Ambassador Phone: - ### - ### ####
NICU BOC Ambassador Email:
Area descriptions of where BOC program is being implemented.

Please help us to better understand where the BOC program is being used at your facility. We appreciate as much detail as possible.

For example, 30-bed inpatient unit, outpatient clinic seeing 60-70 patients per week, small 10-bed pediatric unit in an adult hospital, etc...

If the program is being used in satellite buildings with differing address from the main facility, please indicate where/address.
Additional NICU Ambassador contacts or comments:

Please add any additional NICU Ambassadors here including name, email, and phone number.
Beads of Courage Chronic Program Ambassador Information:
Chronic Beads of Courage Ambassador Chronic Beads of Courage Ambassador First Last
Please complete if you are licensed to use the Beads of Courage Chronic Flagship Program.

If there is more than one, please provide lead ambassador information and include additional names and contacts in the comment section.
Chronic BOC Ambassador Title/Department:
Chronic BOC Ambassador Phone: Chronic BOC Ambassador Phone: - ### - ### ####
Chronic BOC Ambassador Email:
With what medical services/conditions do you use the BOC Chronic Program?

With what medical services/conditions do you use the BOC Chronic Program? CF/Pulmonology Gastrointestinal Solid Organ Transplant Palliative Care/Hospice Rehab Other Other
Area descriptions of where BOC program is being implemented.

Please help us to better understand where the BOC program is being used at your facility. We appreciate as much detail as possible.

For example, 30-bed inpatient unit, outpatient clinic seeing 60-70 patients per week, small 10-bed pediatric unit in an adult hospital, etc...
Additional Chronic Ambassador contacts or comments:

Please add any additional Chronic Ambassadors here including name, email, and phone number.
Beads of Courage Burn Program Ambassador Information
Burn Beads of Courage Ambassador Burn Beads of Courage Ambassador First Last
Please complete if you are licensed to use the Beads of Courage Burn Flagship Program.

If there is more than one, please provide lead ambassador information and include additional names and contacts in the comment section.
Burn BOC Ambassador Title/Department:
Burn BOC Ambassador Phone: Burn BOC Ambassador Phone: - ### - ### ####
Burn BOC Ambassador Email:
Area descriptions of where BOC program is being implemented.

Please help us to better understand where the BOC program is being used at your facility. We appreciate as much detail as possible.

For example, 30-bed inpatient unit, outpatient clinic seeing 60-70 patients per week, small 10-bed pediatric unit in an adult hospital, etc...

If the program is being used in satellite buildings with differing address from the main facility, please indicate where/address.
Additional Burn Ambassador contacts or comments:

Please add any additional Burn Ambassadors here including name, email, and phone number.
Additional Information
How can the BOC team help you?

How can the BOC team help you? Interested in virtual refresher training for BOC Program Would like assistance assuring materials are up to date Need assistance with ordering/billing BOC program(s) are going strong. No assistance needed. Encountering problems or issues with BOC program(s) Interested in collaborating with BOC using virtual programs Have questions/concerns about funding BOC program(s) Interested in starting another BOC program in a new area of the hospital Clinician interest in participating on a clinical advisory group with BOC staff (program assessments, development, mentorship to new BOC Ambassadors, etc...) Other Other

Please check all that apply or let us know if there is another need in the "other" box with a brief description.

We will contact you for assistance or feel free to reach out to krista@beadsofcourage.org directly.
Volunteer needs:

Volunteer needs: Interested in receiving woodturned bowls for BOC members (handmade by BOC donors when available) Interested in receiving BOC bead bags for BOC members (handmade by BOC donors when available) Interested in coordinating BOC-Hospital volunteer ("BOC Encourager") to assist with BOC programming in hospital. (coordinated with BOC and Hospital) Not interested or able to accept/have volunteers or establish donor relations as listed above at this time. Other Other

Please check all that apply or let us know if there is another need in the "other" box with a brief description.

If you have selected an option of interest, we will contact you to discuss the details, or feel free to reach out to krista@beadsofcourage.org directly.
Please share a story or experience on the benefits of implementing BOC with a patient or family:

BOC always loves to hear stories of the program in action. We call these "Mission Moments" as they support the mission of BOC.

Your stories provide powerful testimonies to the value of BOC and are often shared to cultivate and maintain sponsor and donor relations which is critical as a non-profit organization.
Please share any photos of Beads of Courage in action including members and families, staff and clinicians, or the beads themselves.

Attach Files

If providing pictures of anyone under the age of 18, please contact krista@beadsofcourage.org to have a legal guardian complete the photo consent form. This is available to be sent to you/guardian via an email link.
Additional comments, concerns, or questions or any other pertinent contacts with your organization?
Thank you for helping to keep our records up to date. We greatly appreciate your time and commitment to Beads of Courage!

Beads of Courage Flagship Program Ambassador Updates

Beads of Courage Flagship Program Ambassador Updates

Beads of Courage Hematology/Oncology Ambassador information

Beads of Courage Cardiac Ambassador Information

Beads of Courage NICU Ambassador Information:

Beads of Courage Chronic Program Ambassador Information:

Beads of Courage Burn Program Ambassador Information

Additional Information

Thank you for helping to keep our records up to date. We greatly appreciate your time and commitment to Beads of Courage!