Patient and Family Advisory Council Application Form

Date
Name
Address
email
Home Phone
Work Phone
	What is the best way to contact you?
	Home Phone  Work Phone  email
	When is the best time for you to contacted?
	Thank you for taking the time to complete this application for Regions Hospital Patient and Family Advisory Council. Please write brief answers to the following questions in the space provided. Please tell us why you would be interested in being a member of Regions Hospital Patient and Family Advisory Council
	Briefly describe your experience, either as a patient or family member, with receiving care at Regions Hospital.
	What unique perspective do you feel you would bring to the Council?

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All information on this form is considered confidential and is intended for use by Regions Hospital Patient and Family Advisory Council only. You will be contacted upon receipt of this application form to participate in a face-to-face interview. If selected, a background check will be conducted.