Name* First Name Last Name Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home phoneCell phoneEmail address*Preferred contact (choose one):*Home phoneCell phoneEmailThe 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). 2017 to current year 2016 2015 2014 2013 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)*1 to 2 hours per month3 to 4 hours per monthMore than 4 hours per monthAre you available to serve as an advisor for at least 3 years?*You can still support the Advisory Council if you answer "no."YesNoHow 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 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 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 CAPTCHANameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.