Beads of Courage Flagship Program - Information Intake Form

Thank you for your interest in starting a Beads of Courage Program at your institution. Please be as detailed as possible while completing this form. It helps us learn more about your program in order to meet the needs of the patients and families you are serving with Beads of Courage.

Name of organization/hospital

Please provide the full name of the organization/hospital as it should appear on legal documents.
Main Contact Main Contact First Last
Main Contact Email
Main Contact Phone
Organization/Hospital Address Organization/Hospital Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Beads of Courage Program(s) Information
Which Beads of Courage Program do you wish to start (check all that apply):

Which Beads of Courage Program do you wish to start (check all that apply): Hematology/Oncology Neonatal Intensive Care (NICU) Cardiac Burn Chronic (appropriate for chronic conditions, ICUs, trauma, palliative care, etc...); please specify below:

Please indicate what medical service(s) you are hoping to use Beads of Courage within your facility.
Please specify which BOC programs are already licensed to use at your organization:

Please specify which BOC programs are already licensed to use at your organization: Hematology/Oncology Neonatal Intensive Care (NICU) Cardiac Burn No exisiting Beads of Courage Program Chronic (please indicate what population this is used with):

Please check all that apply.
Material Shipping Address Material Shipping Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
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.
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.
Main BOC Staff/Ambassador 1 Main BOC Staff/Ambassador 1 First Last
Main BOC/Ambassador 1 Title and Department
Email
Phone
Main BOC Staff/Ambassador 2 Main BOC Staff/Ambassador 2 First Last
Main BOC/Ambassador 2 Title and Department
Email
Phone
Administration/Leadership

An administrator that oversees all patient/family services in the areas where the BOC program will be used
Name Name First Last
Title
Email
Phone
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.
What is the size of the area in your hospital/organization where you hope to begin Beads of Courage?

What is the size of the area in your hospital/organization where you hope to begin Beads of Courage? Small (i.e./Pediatric Unit on one floor of an adult hospital...only one area needs to be equipped with BOC materials) Medium (i.e./ inpatient unit and clinic area...2 areas needing to be equipped with BOC materials) Large (i.e./Major healthcare instituion or children's hospital needing BOC materials in multiple areas/services...3 or more areas needing to be equipped with BOC materials)
Please provide the most accurate descriptions of the areas where you would like to start BOC including # of beds, average length of stay, patient demographics, etc...)

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.
How many patients do you estimate supporting annually with BOC? (guesses are fine!):
Funding
Do you have funding secured?

Do you have funding secured? Yes No

If yes, please complete the next section.
Funding Organization
Funding Organization address Funding Organization address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Funding Organization Main Contact
Funding Organization main contact phone: Funding Organization main contact phone: - ### - ### ####
Funding Organization Main contact email:
Is the Funding Organization the same organization, contact and mailing address for billing/invoices?

Is the Funding Organization the same organization, contact and mailing address for billing/invoices? YES NO We do not have funding secured yet.
If the billing invoice info is different than funding source, please enter the information for invoicing (Organization, Contact Name, Invoice mailing address, Contact email, Contact Phone).
If you have an allotted budget approved to start a BOC program, please indicate here: $ Dollars . Cents
Are there any other details that you wish to share about your hospital/organization in regards to starting a Beads of Courage program?
Other contacts

If possible, please provide any other pertinent contacts below.
Signatory Name (for legal agreements): Signatory Name (for legal agreements): First Last
Signatory email:
Hospital CEO Name: Hospital CEO Name: First Last
Hospital CEO Email:
Nursing Director's Name: Nursing Director's Name: First Last
Nursing Director's email
Public Relations Representative Name: Public Relations Representative Name: First Last
Public Relations Representative email:
Legal Department Contact name: Legal Department Contact name: First Last
Legal Department Contact email:
Foundation contact name: Foundation contact name: First Last
Foundation Contact email:
If Beads of Courage will need to register with your organization to process start up and materials invoices, please enter that contact's name, title, email and phone here:

Beads of Courage Flagship Program - Information Intake Form

Beads of Courage Flagship Program - Information Intake Form

Beads of Courage Program(s) Information

Main Beads of Courage Staff/Ambassador

Administration/Leadership

Hospital/Organization Information

Funding

Other contacts