AHSH Community Advisory Council Application

Community Advisory Council Application
Applicant Information
Name*

FirstLast
Email*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please tell us about your experience at Adventist Health St. Helena
Have you or a loved one ever been a patient at Adventist Health St. Helena or any of our clinics in the past two years?*

YesNo
Please select all that apply*

HospitalClinic
How would you describe your hospital experience at Adventist Health St. Helena and clinics? *
Please tell us more about you
Do you volunteer in your community? If so, for which organizations?*
Are you able to attend in person meetings at Adventist Health St. Helena during weekdays?*

YesNo
Eligibility Criteria
Are you willing to sign an agreement promising not to disclose confidential information given to you in your role as a member of the Community Advisory Council for Adventist Health St. Helena?*

YesNo
Should be Empty:

Community Advisory Council Application