Patient and Family Advisory Council Application

To apply to become a member of the PFAC, please complete the application below.

Name

Date

Address

City

Zip Code

Phone

How did you hear about the council?

Describe why you would like to be a member of the Patient & Family Advisory Council.

What does “good patient experience” mean to you and your family when you use the hospital?

What are some of the specific things that health care professionals do to help you and your family?

Share some examples of organizations or committees you have served and your hobbies and interests.

Please provide the contact info for two references. For each, please include a name, along with a phone number and/or email address.

Patient and Fam­i­ly Advi­so­ry Coun­cil Application