Community Advisory Councils Application

Community Advisory Council Application Form

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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
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Community Advisory Councils Application

Community Advisory Councils Application

Community Advisory Council Application Form

The following questions will help us get to know you better.

Please tell us about yourself.

Check skills, experience and/or education.

Services

Featured services

All Services ›

Services

Featured services

All Services ›

Locations

Careers

Patients & Visitors

Featured services

All Services ›

Find a Doctor ›

Search Locations ›

Community Advisory Councils Application

Community Advisory Councils Application

Community Advisory Council Application Form

The following questions will help us get to know you better.

Please tell us about yourself.

Check skills, experience and/or education.

Provident Hospital's HVAC system has been impacted by the extreme heat.