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About the Pediatric Neurosurgery Fund
Hope Stones Program Registration

(Please note that fields with the red triangle are required.)


Child's Name:
Parent / Guardian Name:
Address:
City:
Province:
Postal Code:
Email Address:
Phone Number:
Diagnosis:
Primary Hospital / Clinic:
Primary Doctor:
   

Below is a list of Procedures and the corresponding Hope Stone.
Please fill out the number required by the Child based on the
number of procedures they have undergone
.


Admission to Hospital Attended Camp Catheter, Tubes or
Drains In & Out
Central line or
PICC line
Clinic Visit
Teddy Bear Tree/Camping Gold Sphere Silver Heart Marine Animal
         
Brain or Spinal Surgery Biopsy Dental Discharge Dressing Change
Four Leaf Clover Tube Bead Tooth Bead Happy Face Red Round
         
ER Visit EVD Glenrose Hospital Intubation & Extubation Isolation
Farm Animal Fruit Peace Sign Purple Star Hand
         
IV Start & Stop Major Milestone MRI, CT Scan or Ultrasound NPO Other Surgeries
Silver Star Angel Snowflake Silver Sphere Sports
         
Other Tests or Scans Orthotics - Foot/Hand Braces & Helmets Oxygen, CPAP or
BiPAP
Physio or
Occupational Therapy
PICU or
NICU Admission
Black/Silver Donut Foot Clear Sphere Candy Blue Heart
         
Needle Pokes &
Blood Work
Procedure Bead Satellite Visit School Shunt Infection
Red Heart Safari/Jungle Moon Music Orange Donut
         
Shunt or Reservoir Tap Sutures or Staples Removed TPN Transfusion Transport of Any Kind
Birds Butterfly/Lady Bug Hot Pink Flower Transportation
         
Wound Infection X-ray      
     
Green Sphere Gold Heart