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Please provide the full name of the organization/hospital as it should appear on legal documents.
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Beads of Courage Program(s) Information
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Which Beads of Courage Program do you wish to start (check all that apply):
Please indicate what medical service(s) you are hoping to use Beads of Courage within your facility.
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Please specify which BOC programs are already licensed to use at your organization: *
Please check all that apply.
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Please provide the best address for shipping purposes. This will be used to ship all materials to begin the program after the legal agreement is executed and payment is made.
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Main Beads of Courage Staff/Ambassador
These are staff that will be the leads of the BOC program at the facility. It is preferable to identify at least 2 staff if possible.
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Administration/Leadership
An administrator that oversees all patient/family services in the areas where the BOC program will be used
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Hospital/Organization Information
Please thoroughly complete the section below. This allows BOC to assess what will be needed to provide the best Beads of Courage experience when starting a new program, as well as assist us in providing the best cost of starting an new program.
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What is the size of the area in your hospital/organization where you hope to begin Beads of Courage? *
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If BOC will be used in more than one area/unit, please describe each separately.
The more information that can be provided, the better BOC can be prepared to meet your needs.
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Funding
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Do you have funding secured? *
If yes, please complete the next section.
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Is the Funding Organization the same organization, contact and mailing address for billing/invoices? *
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If you have an allotted budget approved to start a BOC program, please indicate here:
$
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Other contacts
If possible, please provide any other pertinent contacts below.
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