Name

Address

Primary Phone

Secondary Phone

Email Address

GenderMaleFemale

Age Range
18-2526-4142-5758 and above

Language SpokenEnglishArabicFrenchSpanishOther

I am the
PatientParentSpouseSiblingOther

I/my family member was treated in...

Educational LevelHigh SchoolBachelorsDoctorate (PhD)AssociateMastersOther

Tell us about how you can help the Patient and Family Advisory Council (PFAC)

Why would you like to be a member of the PFAC?

If you have served on other advisory councils and boards, or as a volunteer with other groups, please briefly describe that experience?

The key attributes of a good PFAC member include being a good listener, having excellent communication skills, respecting the opinion of others, working collaboratively, and maintaining confidentiality. Do you believe you have these attributes and why?

What special interests, experiences or talents would you offer the PFAC?