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608.348.2331
Search
Find A Doctor
Search Providers
Southwest Health Clinics
View All Providers
About
Awards & Recognitions
Board of Directors
Community Health Needs
Connecting for Healthier Communities
History
Leadership Team
Nondiscrimination Statement
Patient Financial Services
Quality and Pricing
Vision and Values
Visiting Southwest Health
Our Services
Audiology
Birth Center
Cancer Care
COVID19 UPDATES & INFO
Dermatology
Diabetes Education
The EDGE
Emergency & Urgent Care
Emergency Medical Services (EMS)
Eye Center
Financial Assistance
General Surgery
Health Information
Laboratory
Mammography
Massage Therapy
Medical Imaging
Mental Health
Nutrition Services
Orthopedic Institute
Otolaryngology / ENT
Pain Management
Patient Financial Services
Pediatrics
Pharmacy
Pregnancy
Primary Care
Rehabilitation & Therapy
Senior Care
Sexual Assault Support
Sleep Lab
Specialty Clinics
Speech Therapy
Swing Bed Program
Women’s Center
My Healthy Life
Activity
Cancer Support Group
Class Schedules
COVID19 UPDATES & INFO
The COVID Vaccine
Depression Screen for Adults
Food & Eating
Know Your Numbers
Life Apart. Healthy Together.
Minds
Preventive
Programs & Events
Say It Out Loud! Art Contest
Sole Mates Walking Club
Work
Young at Heart
Media
Advertising
Community Engagement
Gallery of Gratitude
Heart 2 Heart Magazine
News
Social Media
Sponsorships & Donations
Videos
Giving
About the Foundation
Donate Online
Employees That Care (ETC)
Golf Outing
Moments of Impact
Scholarships
Volunteer
Ways to Give
Careers
Apply Online
Career Opportunities
Physicians
Student Experiences
Survey
Forms
Appointments
Blog
Baby Gallery
Home
>
Patient and Family Advisory Council Application
Patient and Family Advisory Council Application
PFAC Application
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
Phone
*
Birth Date
*
Primary program/department and/or services involved in your care:
*
Please choose all that apply.
Inpatient
Outpatient
Emergency care
Other programs, departments or services
How did you learn about our Patient and Family Advisory Council?
*
Why would you like to volunteer as an Advisor?
*
Are there any areas of special interest to you?
*
If you have served as an advisor for other programs or organizations, please briefly describe this experience.
How long of a commitment are you willing to make to our program?
*
Please choose the highest degree you have received.
*
Did not graduate high school
High school graduate or GED
Some college credit, no degree
Trade/techinical/vocational training
Associate degree
Bachelor's degree
Master's degree
Professional degree
Doctorate degree
Do you have any physical limitations?
*
Yes
No
If yes, please explain:
Work and Volunteer Experience
*
Present Status:
Student
Employed
Unemployed
Retired
Current or Previous Employer
Length of Employment
References:
*
Please list the name, phone number, and email address of at least one reference who can describe your character. The listed references should not be related to you.
Do you have any special training, organizational memberships, clubs, or hobbies?
*
Are you comfortable with public speaking?
*
Yes
No
Availability
*
Please specify times when you are able to attend meetings:
Daytime
Evening
Weekends
Meeting Time Preference (times may vary)
*
Please choose all that apply:
Morning (8am-12pm)
Afternoon (12pm-4pm)
Evening (4pm-8:00pm)
Meeting Day of the Week Preference
*
Please choose all that apply:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Do you know of other individuals and families who have experienced care at Southwest Health who might be interested in serving as advisors?
If so, please list name and contact information below: