SportsPartner_ChikFilA_FL_WM_24

Get your camera ready: We've partnered with Chick-fil-A to celebrate your newest little nugget! If your baby was born at one of our six participating AdventHealth hospitals, you can enter them for the chance to be named Little Nugget. One winner from each participating hospital will receive a special Chick-fil-A prize pack.

Parent First Name*

Parent Last Name*

Baby First Name*

Baby Last Name*

Phone*

Email*

ZIP Code*

When did you deliver?*

Please note: babies will need to be under one year old

Where did you deliver?*

Enter Your Unique Code*

Would you be willing to share patient testimony?*

Yes No

I, on behalf of myself, or if the Subject is a minor, on behalf of my minor child, grant to AdventHealth on a perpetual, irrevocable and unrestricted basis the right to use, reuse, publish and re-publish Subject’s photographic portraits or pictures and/or electronic/digital/video footage of the Subject that the Subject posted on social media (“Subject’s Likeness”) or the written content, photography or electronic/digital/video footage of Subject’s health care experience and healing at an AdventHealth facility posted on social media (“Subject’s Story”), in which the Subject’s Likeness or Subject’s Story may be included in whole or in part as a composite or distorted in character or form, and whether in conjunction with the Subject’s own name or a fictitious name. The rights granted herein to use the Subject’s Likeness and the Subject’s Story shall extend to any reproductions in color or otherwise, made through any medium and in any and all media now or hereafter known whether used singularly or in conjunction with printed and/or other accompanying material and whether used for any purpose whatsoever, including commercial purposes, and regardless of the manner in which said use is transmitted (e.g., television broadcast, electronic or digital media, printed material, newsprint, brochures, all printed collateral, motion pictures and video).

Please attach photo of your Little Nugget*

No File Chosen

File uploads may not work on some mobile devices.

Must be under 25 MB

By submitting this form, I agree to receive communications from AdventHealth.

Let's Keep In Touch

Yes, I want AdventHealth to send me information about its various services via phone, email or direct mail.

Request Reason

Type

Type - Case

ServiceLine__c

Service Line - ServiceLine__c - Case

Subject

Subject - Subject - Case

Case - Status

Status - Status - Case

Campus_Submitted__c

Campus Submitted - Campus_Submitted__c - Case

Case Origin

Case Origin - Origin - Case

Line__c

Line - Line__c - Case

ReferralPath__c

ReferralPath - ReferralPath__c - Case

ReferralValue__c

ReferralValue - ReferralValue__c - Case

Referral_Source__c

Referral Source - Referral_Source__c - Campaign

Campaign__c

Campaign - Campaign__c - Case

CampaignChannel__c

Campaign Member - Status

Status - Status - CampaignMember

LeadSource

Lead Source - LeadSource - Contact

Email_Opt_In_Description__c

Email Opt In Description - Email_Opt_In_Description__c - Contact

Campaign Name

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Campaign Source

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Campaign Content

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Campaign Medium

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Campaign Term

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Requested_Physician_Name__c

Preferred Physician - Requested_Physician_Name__c - Case

NPI__c

Guide_Choice__c

Guide Choice - Guide_Choice__c - Case

HRA__c

HRA - HRA__c - Case

GCLID (Google Click Identifier)

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