Pediatric Services

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:

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Phone

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