2021 Heart Month - Heart Center at CHOA Patient Family Stories

** Update! We're printing a book!**

Submit your heart warrior's story to see your family featured in our printed book coming later in 2021!

Families who have already submitted a story do not need to re-submit.

Share your Heart Family Story and Journey!

Kids at Heart is preparing for Heart Month/CHD Week 2021! Please help us by sharing your family's heart journey. Fill out the form below to share your story and include a family picture. After you finish the form, you will be directed to an area to fill out a media consent form if you have not already. THANK YOU!

Parent/Guardian First Name

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Parent/Guardian Last Name

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Parent/ Guardian First Name (2nd parent)

Parent/ Guardian Last Name (2nd parent)

Parent Email Address

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Parent phone number

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Heart Child First Name

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Heart Child Last Name

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Your heart child's age (as of February 2021)

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Your heart child's primary cardiac diagnosis or diagnoses

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Add another heart child?

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Yes

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2nd Heart Child's First Name

2nd Heart Child's Last Name

Your 2nd Heart Child's age (as of February 2021)

Your 2nd heart child's primary cardiac diagnosis or diagnoses

Add another heart child?

Yes

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Please write in name(s), age(s), and diagnoses for any additional children with a heart condition:

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Siblings Name(s) and Age(s)

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Would your heart child's sibling(s) be willing to participate in an interview about their experience?

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Yes

N/A my child does not have siblings

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Your Street Address

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City

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State

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Zip

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Your child's cardiologist and clinic location (city)?

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Who was your child's surgeon?

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Tell us about your child's heart journey:
When did you receive their diagnosis? Has your child had any surgeries or procedures? Have you spent time at the hospital? What challenges has your family faced, and what gives you hope? Anything you want to share about your heart warrior and his/her heart journey!

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Share a family photo here! Please identify names of all family members from left to right

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Upload file

List names of family members in your photo, left to right:

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Please tell us a fun fact about your family or anything else you'd like to share!

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