Patient and Family Advisory Council Member Application

Contact Information

Full Name *

Street Address *

City *

State *

Country

Postal Code *

Phone *

Email *

Patient and Family Advisory Council Member Application

Availability

The Patient and Family Advisory Council meets bi-monthly for 90 minutes. Are you able to commit to attending meetings regularly? *

Yes

Optional Demographics (to support diverse representation)

Age (to support diverse representation)

18-29

30-49

50-69

70+

Community or Town *

Preferred Pronouns *

Confidentiality Agreement

I understand that as a Patient and Family Advisory Council member, I may hear or read confidential information about patients, staff or operations. I agree to keep this information private and to uphold Sauk Prairie Healthcare's standards of respect and professionalism.

Patient and Family Advisory Council Member Application

Contact Information

Motivation & Experience

Patient and Family Advisory Council Member Application

Availability

Optional Demographics (to support diverse representation)

Confidentiality Agreement