AHSR Patient and Family Advisory Council Membership Application

Patient and Family Advisory Council Application

Adventist Health Sonora's Patient and Family Advisory Council is a diverse group of patients and staff who meet regularly to advise the hospitals, imaging centers and clinics on how they can provide the highest standard of comprehensive and compassionate health care to everyone. Join our Patient and Family Advisory Council and help us fulfill the Adventist Health mission and vision through your voice.
Applicant Information
Date*

MonthDayYear
Date
Name*

FirstLast
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email*
Select the best method to contact you*

Phone numberEmail
Emergency contact name*
Emergency contact phone number*

Area CodePhone Number
Please check all that apply below:
I am a*

PatientSpouse of a patientFamily member of a patientCaregiverCommunity memberOther
I/my family member has been treated most often in*

ClinicsDialysisHome CareHospiceHospital visitsEmergency roomLabsOncologyOutpatient testing areasRehabSurgeryOther
Tell us more about yourself and your experience
Please tell us about your hospital or clinic experience(s). What would you have improved about the experience? What impressed you about your experience?*
Why do you want to be involved in our Patient and Family Advisory Council?*
Please share with us the strengths and skills you have that would be useful in working on the advisory council?*
If you have participated in any organizations or committees, please share some examples*
These examples may be from work. community or church
Do you know other individuals and/or families who have experienced care at Adventist Health Sonora who might be interested in serving as advisors?*
Is there anything else you would like us to know?*
I can commit to*

1 year2 years
I prefer meetings in the*

MorningAfternoonEvening
Best day of the week is*

MondayTuesdayWednesdayThursdayFriday
Should be Empty:

Patient and Family Advisory Council Application

Applicant Information

Tell us more about yourself and your experience