Skip to content

MyCookCountyHealth

Search

Search

Close this search box.

Services

Services

Featured services

Neurology & Neurosurgery

Primary Care

Emergency Medicine

Cardiology

Family Medicine

OB/GYN

All Services ›

Services

ExpressCare Virtual Immediate Care ›

Featured services

Neurology & Neurosurgery

Primary Care

Emergency Medicine

Cardiology

Family Medicine

OB/GYN

All Services ›
Find a Doctor
Locations

Locations

Search Locations ›

Hospitals

Pharmacies

Community Health Centers

Health Services
Join Our Team

Careers

Join Our Team

Nursing
Patients & Visitors

Patients & Visitors

Visitor Information

Community Resources

Billing and Insurance

Request Medical Records

COVID-19 Information

Good Faith Estimates

Patient Experience

Contact Us

Patient Gift Shop

Search

Search

Close this search box.

Request Appointment

Services

Featured services

Neurology & Neurosurgery

Emergency Medicine

Family Medicine

All Services ›

Find a Doctor

Find a Doctor ›

Locations

Community Health Centers

Health Services

Search Locations ›

Patients & Visitors

Visitor Information

Billing and Information

Covid-19 Information

Patient Gift Shop

Community Resources

Request Medical Records

Good Faith Estimates

Community Newsletter

Careers

MyCookCountyHealth Login

Request Appointment

Financial Assistance

About Cook County Health
Strategic Plan 2023-2025
Physician Directory
Office of Behavioral Health
Board of Directors
Human Resources
Employment Plan Office
Senior Leaders
The Change Institute of Cook County Health
Contribute
Doing Business with Cook County Health

Menu

About Cook County Health
Strategic Plan 2023-2025
Physician Directory
Office of Behavioral Health
Board of Directors
Human Resources
Employment Plan Office
Senior Leaders
The Change Institute of Cook County Health
Contribute
Doing Business with Cook County Health

Community Advisory Councils Application

Community Advisory Councils Application

Community Advisory Council Application Form

Name*
First Name Last Name
Address*
Street Address Address Line 2 City State ZIP Code
Home phone
Cell phone
Email address*
Preferred contact (choose one):*
The following questions will help us get to know you better.
Are you a…*
- Patient
- Caregiver or family member of a patient
- Local community leader
- Representative of a religious organization
- Staff member of a community development organization
- Healthcare professional
If a patient or family member, when was your care experience at this Clinic? (Check all that apply).
- 2020 to current year
- 2019
- 2018
- 2017 or before
What language(s) do you speak?*
We recognize that our community advisors have busy lives. How much time are you able to commit? (Check one)*
Are you available to serve as an advisor for at least 3 years?*
You can still support the Advisory Council if you answer “no.”
How do you want to help? I want to:*
- Serve as a member of the Citizen Advisory Council. Advisory Council members should be ready to commit to serving on for at least 2-3 years. The Council meets once a quarter for 1 ½ to 2 hours.
- Make thoughtful recommendations on issues affecting Clinic operations, patient services and quality improvement projects.
- Strengthen communication and collaboration among patients, families, caregivers and staff.
- Partner with staff on short or long-term projects.
- Promote clinic services to clinic constituency.
- Fundraise for special clinic projects.
- Staff community health fairs and other educational activities
- Ensure everyone has access to healthcare by supporting health insurance enrollment outreach efforts.
- Other issues (please describe):
Other:
Please tell us about yourself.
Why do you want to serve on the Community Advisory Committee?*
Briefly describe any experience you may have as a community leader or public speaker.*
List employment and/or volunteer experience.*
Check skills, experience and/or education.
Special skills*
- Fundraising
- Personnel/Human Resources
- Marketing/Public Relations
- Finances
- Technology
- Legal
- Management
- Other
Professional background*
- For-profit business
- Nonprofit
- Government
- Other (please specify):
Other:
Education*
- Some high school
- High school graduate
- Some college
- Undergraduate college degree
- Some graduate coursework
- Graduate degree or higher
- Other (please specify);
Other:
Other affiliations:
Board or committee service:
Finally, which locations are you interested in participating:
- Arlington Heights Health Center, 3250 N. Arlington Heights Road, Arlington Height, IL 60074
- Austin Health Center, 4800 W. Chicago Avenue, Chicago, IL 60651
- Belmont Cragin Health Center, 5501 W. Fullerton, Chicago, IL 60639
- Blue Island Health Center, 12757 S. Western Avenue, Blue Island, IL 60406
- Cottage Grove Health Center, 1645 S. Cottage Grove Avenue, Ford Heights, IL 60411
- Dr. Jorge Prieto Health Center, 2424 S. Pulaski Avenue, Chicago, IL 60623
- Englewood Health Center, 1135 W. 69th Street, Chicago, IL 60621
- North Riverside Health Center, 1800 S. Harlem Avenue, North Riverside, IL 60546
- Provident Hospital/Sengstacke Health Center, 500 E. 51st Street, Chicago, IL 60615
- Robbins Health Center, 13450 S. Kedzie Avenue, Robbins, IL 60472
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Search Locations

Request an Appointment

About Us

About Cook County Health

Strategic Plan 2023-2025

Physician Directory

Office of Behavioral Health

Board of Directors

Human Resources

Employment Plan Office

The Change Institute of Cook County Health

Doing Business with Cook County Health

For Medical Professionals

Fellowship Programs

Residency Programs

Education & Research

Provident Scholarship Fund

Get In Touch

Stay Updated

Community Relations

Connect With Us

Facebook-f X-twitter Instagram Tiktok Youtube Linkedin

Copyright © 2024 Cook County Health. All Rights Reserved.

Employee Login
Privacy Policy
Price Transparency
Sitemap

Community Advisory Councils Application

English

Español de México