Survey - Patient Ambassador 1st Round Survey: Class of 2026-2027

2026-2027 Patient Ambassador Questionnaire

Patients selected for the Ambassador Program display extraordinary strength and courage in the face of tremendous medical challenges. If selected, they share their personal stories at fundraising events and in marketing materials to inspire generosity and philanthropic support for Children’s Colorado.

By sharing their personal experiences and healthcare journeys, patient Ambassadors connect the impact of philanthropic giving to the hospital's mission, encouraging community engagement and donations.

Throughout their two-year participation in the program, Patient Ambassadors and their families share their stories publicly, help raise money, represent Children’s Colorado at fundraising events, and are featured in donor materials.

For families who have been nominated, please fill out the following form. After this information is reviewed, the patient and family will be contacted by a Foundation team member so they can learn more about the patient’s specific Children’s Colorado journey. Patients/families can learn more about the Ambassador Program at that time.

Completing these questions is solely for the purpose of assessing the patient/family’s ability to fulfill the Ambassador role and will have no impact on their current or future care. This questionnaire will close on Sunday, May 11, 2025 at midnight MDT.

If you have any questions, please reach out to Ambassadors@childrenscoloradofoundation.org.

Thank you for taking the time to share more about your story!

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Question - Required - Patient's First Name:

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Question - Required - Patient's Last Name:

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Question - Required - Do you give permission to share the below information with Children's Hospital Colorado Foundation?

Primary Guardian's Contact Information

Please fill out your information below

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Name:

First Required	Last Required

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Email: Required

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Street 1: Required

Street 2:

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City/State/ZIP:

City Required	State Required	ZIP Required

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Phone Number: Required

You may receive periodic communications from Children's Hospital Colorado Foundation. You can manage your email preferences at any time by logging into our site or by contacting us.

Keep me logged in. What's this?

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Question - Required - What is Primary Guardian's relationship to Patient?

Question - Not Required - If "Other", please briefly specify:

If Patient lives in different address than Primary Guardian, please fill the following below:

Question - Not Required - Patient's Street Address:

Question - Not Required - Patient's City:

Question - Not Required - Patient's State:

Question - Not Required - Patient's Zipcode:

Patient's Additional Information

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Question - Required - List sibling name(s), age(s) and date of birth(s)

Question - Not Required - Siblings Info 01:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Siblings Info 02:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Siblings Info 03:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Siblings Info 04:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - If applicable, would siblings be interested in participating in Ambassador related activities?

Question - Not Required - Patient's Race and Ethnicity

	American Indian or Alaskan Native
	Asian
	Native Hawaiian or Other Pacific Islander
	Black or African American
	Hispanic or Latino/a/x
	White
	My identity is not listed here
	I prefer not to answer

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Question - Required - Is anyone in the Patient's immediate family active-duty military or a veteran?

Question - Not Required - If Yes, who in Patient's family is actively serving or a veteran?

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Question - Required - Are you using Medicaid, Tricare, or some other form of insurance to address the costs of care?

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Question - Required - What brought you to Children's Hospital Colorado?

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Question - Required - What are the different areas of the hospital involved in your care? You may select multiple answers.

	Center for Children's Surgery
	Center for Cancer and Blood Disorders
	Child Health Research/Research Studies
	Digestive Health Institute
	Heart Institute
	Precision Medicine
	Pediatric Mental Health
	Other

Question - Not Required - If "Other", would you briefly describe?

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - In your opinion, what makes Children's Colorado special?

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Question - Required - What was your most positive memorable experience at Children's Colorado?

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Question - Required - Who are some of your favorite caregivers at Children's Colorado and why?

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Question - Required - Why do you think it's important for the community to support Children's Colorado?

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Question - Required - What is something unique about you? What are your interests and special talents?

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Question - Required - What did Children's Colorado do for you/your family that was unique to your specific need/story?

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Question - Required - What are your dreams for the future or what would you like to be when you grow up?

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Question - Required - What are you most proud of?

Nominated patients/guardians will be contacted by a Children’s Colorado Foundation team member to learn more about their story. Patient Ambassador stories celebrate different backgrounds, cultures, ages, abilities, diagnoses, regional locations and treatment areas. While each patient has their own unique and inspirational story, we are only able to select 25 patients for the 2026-2027 Patient Ambassador Class. All patient stories are important and have a role to play in supporting Children’s Colorado. Any patient who is not selected to be a Patient Ambassador for this class will have opportunities to share their story to support the Children’s Colorado Foundation mission.

Question - Not Required - Siblings Info 05:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Siblings Info 06:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Siblings Info 07:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Siblings Info 08:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What makes CHCF special 01:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What makes CHCF special 02:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What makes CHCF special 03:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What makes CHCF special 04:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What makes CHCF special 05:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What makes CHCF special 06:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What makes CHCF special 07:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What makes CHCF special 08:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Positive memorable experience at CHCF 01:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Positive memorable experience at CHCF 02:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Positive memorable experience at CHCF 03:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Positive memorable experience at CHCF 04:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Positive memorable experience at CHCF 05:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Positive memorable experience at CHCF 06:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Positive memorable experience at CHCF 07:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Positive memorable experience at CHCF 08:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Favorite caregivers at CHFC 01:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Favorite caregivers at CHFC 02:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Favorite caregivers at CHFC 03:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Favorite caregivers at CHFC 04:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Favorite caregivers at CHFC 05:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Favorite caregivers at CHFC 06:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Favorite caregivers at CHFC 07:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Favorite caregivers at CHFC 08:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Why it's important for community to support CHCF 01:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Why it's important for community to support CHCF 02:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Why it's important for community to support CHCF 03:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Why it's important for community to support CHCF 04:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Why it's important for community to support CHCF 05:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Why it's important for community to support CHCF 06:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Why it's important for community to support CHCF 07:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Why it's important for community to support CHCF 08:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient interest and special abilities 01:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient interest and special abilities 02:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient interest and special abilities 03:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient interest and special abilities 04:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient interest and special abilities 05:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient interest and special abilities 06:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient interest and special abilities 07:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient interest and special abilities 08:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - CHCF unique treatment to your specific need 01:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - CHCF unique treatment to your specific need 02:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - CHCF unique treatment to your specific need 03:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - CHCF unique treatment to your specific need 04:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - CHCF unique treatment to your specific need 05:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - CHCF unique treatment to your specific need 06:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - CHCF unique treatment to your specific need 07:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - CHCF unique treatment to your specific need 08:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's future dream 01:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's future dream 02:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's future dream 03:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's future dream 04:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's future dream 05:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's future dream 06:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's future dream 07:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's future dream 08:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's most proud of 01:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's most proud of 02:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's most proud of 03:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's most proud of 04:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's most proud of 05:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's most proud of 06:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's most proud of 07:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Patient's most proud of 08:

(Maximum response 255 chars, approx. 5 rows of text)