Register to join the TLC for Kids Healthcare Portal – TLC for Kids Healthcare Professionals Portal

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Registration Information
Registration Type*
Name*
First Last
Hospital / Clinic / Institution*
Department(s)*
Job title*
Public or Private*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

No PO Boxes - only physical street addresses accepted
Work Phone*
Mobile
Work Email*
Please note that we only accept work email addresses, not personal addresses such as @hotmail.com or @gmail.com.
Enter your work email Confirm your work email
Password*
Enter Password Confirm Password

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Additional Information
How long have you been with this hospital / clinic?*
How long have you been with this department?*
Are you:
How many treatments, procedures or examinations does your department provide to Paeds on a weekly basis?*
Please describe the types of support the families you will be requesting on behalf of may need the most.
How did you hear about this program?*
How do you think the Distraction Box™ would benefit your service?
In what circumstances would you use the Distraction Box™?
On a weekly basis, how often do you think you would use the Distraction Box™ (approximates are fine)?
Any other information you would like to share with us?*
By checking the box below, you agree the above details are correct*
- I agree
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Registration Information

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