Child Life Special Events Application

PLEASE NOTE: Event requests require 4 to 6 weeks for processing. Holiday event requests (December and January) must be received by November 1.

Asterisk (*) indicates a required field.

Contact Information

Contact Name*

Address 1*

Address 2

City*

State/Province/Region*

Zip/Postal Code*

Phone Number*

Fax Number

Email Address*

Previous Event Information

Have you done a special event for St. Jude in the past?*

Yes No

If yes, who was your contact person?

Do you have a personal connection to St. Jude/ALSAC (ie, current/former patient, family member of patient, family member of employee)?*

Yes No

If yes, please explain.

Current Event Information

Program Name*

Is this an ALSAC event?*

Yes No

Number of people in group*Maximum group size is 10

Type of event*

Arts & Crafts Games Movement/Performance Music

Event description and details

Estimated duration of program?*Maximum length of program is 45 minutes

20 minutes 30 minutes 45 minutes

Set-up time required?*

No set up 20 minutes 30 minutes 45 minutes

Breakdown time required?*

No breakdown 20 minutes 30 minutes 45 minutes

Bringing supplies?*(your group must provide their own supplies)

Yes No Not applicable

Plan to bring gifts?*(Stuffed animals, clothing and food are not allowed)

No Yes, List gifts

Arrive in costume?*

Yes No Not applicable

Other places you have performed, contact person at each site, and telephone number*

Needs

Equipment Needs

Tables Chairs Electrical outlet access

Parking Needs*

Car Bus Van

Number of Vehicles*

Dates you would like to host the event

For evening or weekend events, please see the housing facility pages

Preferred Date*

First Alternate Date*

Second Alternate Date*

Submission

I have read and understand the Patient Event Guidelines.

Initials*

I agree to share this information with St. Jude*
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