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Good Medicine Joy Gram Form
Fill out this form with info about your kiddo and Good Medicine will send you a personalized video for them to bring a little bit of joy. We will send the video 5 days after receiving this unless you want it sent on a specific date.
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* Indicates required question
Child's first name and pronouns
*
Your answer
Child's age
*
Your answer
Child's favorites (colors, hobbies, performing artists, sports)
*
Your answer
Does your child have any siblings? Are they older or younger?
*
Your answer
Anything else you want us to know to help make our video specific for your child?
*
Your answer
We will send the video 5 days after receiving this. I
f you want us to send it sooner or on a specific date please list the date below.
MM
/
DD
/
YYYY
Where do you want us to send the video?
Please put your
cell phone
and/or
email
so we can send the video to you. (
We will not store this information for any other purposes.)
*
Your answer
Check the box for permission to send to the email or phone number you provided above. Standard data rates apply.
*
I give permission to send a joy gram video to the email address or phone number provided above.
Other:
Required
How did you hear about the Joy Gram?
*
Nationwide Children's Hosptial
Ronald McDonald House
Instagram
Facebook
Tiktok
Friend
Other:
If you want to be put on the mailing list about Good Medicine events and programs please list your email here.
*
Your answer
Good Medicine is non-profit. Want to make a
DONATION
to our pediatric program?
You can just click the link here. Thank you for investing in joy!
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