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Community Advisory Councils Application

Community Advisory Councils Application

Community Advisory Council Application Form

Comments
This field is for validation purposes and should be left unchanged.
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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