AHLM Community Advisory Committee 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 Lodi Memorial

Have you ever been hospitalized at Adventist Health Lodi Memorial for more than 24 hours?*

YesNo

How long was your longest hospitalization at Adventist Health Lodi Memorial?*

Have you ever been a caregiver for a patient who has been hospitalized at Adventist Health Lodi Memorial for more that 24 hours?*

YesNo

How long was the longest hospital stay of the person you were caring for?*

How many times have you or the person in your care been hospitalized at Adventist Health Lodi Memorial in the last three years?*

How would you describe your hospital experience at Adventist Health Lodi Memorial?*

What did the hospital do well during your or your loved one's stay?*

What could the hospital have done better?*

Please tell us more about you

Do you volunteer in your community? If so, for which organizations?*

Do you feel comfortable working in groups, speaking up and providing input?*

Eligibility Criteria

Is English your first language?*

YesNo

What is your primary language?*

Are you able to attend meetings at Adventist Health Lodi Memorial during weekdays?*

YesNo

Are you able to attend meetings at Adventist Health Lodi Memorial during evenings?*

YesNo

Are you willing to take the necessary immunizations to serve on the Patient Family Advisory Council for Adventist Health Lodi Memorial?*

YesNo

Are you willing to sign an agreement promising not to disclose confidential information given to you in your role as a member of the Patient Family Advisory Council for Adventist Health Lodi Memorial?*

YesNo

Are you willing to undergo a background check?*

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.

Community Advisory Council Questionnaire