Committee Member Application Form

Committee Member Application Form
Accessibility Advisory Committee or Patient and Family Advisory Council
Thank you for your interest in being a member of the Accessibility Advisory Committee or the Patient and Family Advisory Council.
- If you are able to volunteer between one (1) to four (4) hours a month (usually 1 hour a month) then please complete this application and return it:
- to the main registration desk at Erie Shores HealthCare or
- via email to patient.experience@eshc.org or
- by mail to Erie Shores HealthCare, c/o Patient Experience 194 Talbot St. W., Leamington, ON N8H 1N9
Name (First, Last)*
Preferred Name/Preferred Pronouns
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Home Phone
The Committee I am applying to (you may apply to more than one):*

Accessibility Advisory CommitteePatient and Family Advisory Council
The Accessibility Advisory Committee:
- Recognizes and supports accessibility initiatives within Erie Shores HealthCare;
- Ensures organizational compliance with the requirements of the Accessible Customer Service Standard of the Accessibility for Ontarians with Disabilities Act (AODA);
- Creates awareness and ensures compliance with the ESHC Accessibility Policy, the Accessibility Standards for Customer Service and Integrated Accessibility Standards Regulation IASR;
- Provides input to the multi-year Accessibility Plan ;
- Identifies, removes and prevents barriers to people with disabilities who live, work or use the Hospital; and
- Promote public awareness and sensitivity about accessibility issues for persons with disabilities.
You can be a member if:
- You or a family member received care at ESHC in the last 5 years;
- You are a community member or representative of a community organization within Windsor-Essex serving and advocating on behalf of persons living with disabilities; or
- You are an ESHC staff member.
Accessibility Confirmation*

I confirm I meet the above eligibility requirements
The Patient and Family Advisory Council:
- Is committed to improving the quality of care for all patients and family members at ESHC;
- Provides feedback to the hospital based on personal experiences as a patient or family member;
- Engages with other hospital committees regarding quality improvement plans; and
- Works with the hospital for either short- or long-term commitments, depending on the project.
You can be a member if:
- You or a family member received care at ESHC in the last 5 years; and
- You want to improve the quality of care at ESHC based on your personal experience.
PFAC Confirmation*

I confirm I meet the above eligibility requirements
Should be Empty:

Committee Member Application Form

Accessibility Advisory Committee or Patient and Family Advisory Council

The Accessibility Advisory Committee:

The Patient and Family Advisory Council: