AHLM Community Advisory Committee Application

  • Community Advisory Council Questionnaire

  • Applicant Information

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

  • Please tell us more about you

  • Eligibility Criteria

  • Is English your first language?*
  • Are you able to attend meetings at Adventist Health Lodi Memorial during weekdays?*
  • Are you able to attend meetings at Adventist Health Lodi Memorial during evenings?*
  • Are you willing to take the necessary immunizations to serve on the Patient Family Advisory Council for Adventist Health Lodi Memorial?*
  • 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?*
  • Are you willing to undergo a background check?*

  • 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.
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