Patient and Family Advisory Council Application

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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.*

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:

Patient and Family Advisory Council Application

PFAC Application