Patient Family Advisor Application

Requirements to Volunteer:

* 18 years of age or older

* Patient or family member of a patient, who received healthcare (hospital, clinics, rehab, lab, imaging, etc.) within the past 3 years

* Be able to attend regular meetings (occur on the 2nd Thursday of every month)

* Membership duration of two (2) years that can be renewed for a span of four (4) years. (Term subject to change)

If this committee appeals to you, please fill out and submit the following application. Thank you for your consideration.

Name *
Name
Address *
Address
Phone *
Phone

When was your care experience at this hospital? *
Check all that apply

Which unit(s) provided care for you or your family member? *
Check all that apply

You can still be an advisor if you answer “no”.

How do you want to help? *
Check all of your interest areas.