Teen Advisory Council Nomination Form

Thank you for your interest in the Teen Advisory Council at Children’s Hospital & Medical Center! Nominees should be current Children’s patients who have been receiving care for at least one year. Siblings of current Children’s patients are also encouraged to apply. (If you are a sibling nominee, please refer to your sibling’s medical information where requested below).

Members must be between the ages of 13 – 19 and should be comfortable speaking and participating in a small group setting. A recommendation letter from an adult is a necessary part of the nomination. You will be asked to upload it below. This letter will be kept confidential. It should focus on the positive qualities you can share with the council and anything the adult thinks our selection committee should know about you.

Please fill out the information below. In order to recruit a diverse council that represents different medical specialties and backgrounds, we are not able to accept every nominee.





































  • Emergency Contact Information







  • has my permission to participate in the Teen Advisory Council at Children's Hospital & Medical Center. I understand that my child is responsible for getting him/herself to and from the meetings.

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