Lehigh Valley Reilly Children’s Hospital Community Visitor Application

Lehigh Valley Reilly Children’s Hospital Community Visitor Application

Thank you for your interest in visiting Lehigh Valley Reilly Children’s Hospital(LVRCH)! We are appreciative of your support and are excited to learn more. Please complete the below application to share more about your intent to visit the hospital.
Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Organization Name (Optional)
Description of Visit Request*
All visitors are expected to provide a service that enhances a patient’s experiencesuch as entertainment or therapeutic support. Please share why you arerequesting to visit LVRCH and what experience you aim to provide to thepatients and families being treated at the hospital.
Are you requesting to visit a specific department?*

YesNo
If yes, please specify.*
Number of People*
Groups are limited to 8 people
Are attendees above 18 years old?*

YesNo
Date*

MonthDayYear
Desired date is required to be a minimum of two months in advance for planning purposes.
Will you be requesting media coverage?*

YesNo
Media coverage is not something that can be guaranteed during hospital visit.
Affiliation to Lehigh Valley Reilly Children’s Hospital*
Tell us more about your connection to LVRCH and what has inspired you to get involved.
Additional comments*
Please include any other details you wish to share to best capture your request.
I understand that:
- Completion of this application does not guarantee that my group will be able to visit.
- All members of my group are above 18 years old.
- Visits and Performances must be scheduled Monday through Friday between 10:00 a.m.and 3:00 p.m. and should last no longer than 1 hour.
- Any character or mascot must be approved. We will provide pictures of the costume and/or mascot for consideration prior to the visit.
- No one should enter the hospital if he/she has any signs or symptoms of illness.
- No one in my group has been exposed to or has symptoms of flu, measles, mumps, hepatitis, chicken pox, fever, rash, diarrhea, vomiting or the common cold within the past two weeks.
- We cannot take pictures or videos of the patients.
- We cannot ask patients, families or staff to share information related to the patient’s medical diagnosis or any other personal information.
- We cannot exchange phone numbers or addresses with patients.
- We must perform hand hygiene with a hospital approved hand sanitizer at the direction of the staff.
- We cannot eat or drink at the hospital.
- We must dress in a casual but professional manner. Noting that the following types of clothing are prohibited: open toed shoes, short skirts or shorts, tank tops, midriff or sleeveless tops, ripped clothing, and any clothing with logos, religious, political and/or inappropriate messaging.
- We will avoid wearing perfume or cologne.
- Tattoos must be child friendly. We will cover any tattoo that could be considered offensive, so it is not visible.
- We must follow the instructions of the hospital staff person escorting us through the hospital.
- Activities cannot promote one religion or political affiliation.
- If items are distributed, they must be approved by staff.
- We will reach out if we will be late for our scheduled appointment.
- We are aware that our visit may be suspended completely on the advice of security personnel, law enforcement, the infection control department, or during an emergency.
As a representative of the above-named organization, I have read the guidelines for community visitors at Lehigh Valley Reilly Children’s Hospital and affirm my group’s willingness to adhere to these guidelines.*

I agree
Your request will be processed and reviewed by staff at Lehigh Valley Reilly Children’s Hospital within 7-10 business days. A representative will be in contact with any questions or follow-up. Thank you!
Should be Empty: