AHKC Community Advisory Council Application

Community Advisory Council Application

The Community Advisory Council is a forum where members of Adventist Health Kern County community serve as partners and advisors to transform perception and experience for the community, patients and associates.
Email*
Name*

FirstLast
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Are you 18 or older?*

YesNo
Preferred language*

EnglishSpanish
Hospital visit took place at:

Adventist Health BakersfieldAdventist Health DelanoAdventist Health Tehachapi Valley
Primary care visit took place in:

BakersfieldCal CityDelanoMojaveTehachapiWasco
Are you willing to share your contact information with the other Community Advisory Council members?*

YesNo
I am a*

PatientSpouse of a patientFamily member of a patientCaregiverCommunity memberOther
I/my family member has been treated most often in (check all that apply)*

ClinicsDialysisHome CareHospiceHospital visitsEmergency roomLabsOncologyOutpatient testing areasRehabSurgeryOther
Have you ever volunteered in your community?*

YesNo
Why are you interested in becoming a member of the Community Advisory Council?*
Would you be willing to join our engagement community, to provide ideas and feedback to help make decisions that impact the care we deliver?*

YesNo
By providing your details and clicking "Submit" you agree to:
- Receive communications from Adventist Health through email, SMS, text, or calls by an automated telephone dialing system for the purpose of Adventist Health maintaining its relationship with you and providing you information related to services you may be interested in.
- Adventist Health collecting and disclosing to third parties personal information and communications for the purpose of fulfilling your inquiries or requests for services or information.
Should be Empty: