Patient Advisory Council Application

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Date Submitted

Primary Phone Number(Required)

Alternative Phone Number

Best time to call(Required)

Email Address(Required)

The following questions are designed to help us get to know our potential Patient/Family partners better, and to help us build a diverse group of volunteers. All answers will be kept confidential.

Primary language spoken :(Required)

If yes, please describe your relationship :

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What clinic do you (and/or your family) receive most of your health care :

Who is your Primary Care Provider?(Required)

Please describe your availability (specify days of the week and hours of the day) :

Do you have areas of special interest or expertise to offer? If yes, please explain.

What do you hope to contribute to the Parents/Family Advisory Council?

Is there anything else you would like us to know about you or your healthcare experience?

I understand that completion of this Form does not bind the candidate or the program coordinators in any way. The Patient /Family Advisory Council coordinators will choose participants that best meet the needs of the program and assign them accordingly. Before participating in the Council you will be required to complete a formal training program.

Patient Advisory Council Application

Patient Partner Advisory Council

The following questions are designed to help us get to know our potential Patient/Family partners better, and to help us build a diverse group of volunteers. All answers will be kept confidential.