Name
*
Phone Number
*
Format: (000) 000-0000.
Email
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preferred contact method?
*
Phone
Email
Postal Mail
My experience with St. Anthony in the past has been as (check all that apply):
*
Patient
Family Member of Patient
Neither
Are you able to commit to a ONE hour meeting every three months?
*
Please Select
Yes
No
What time of the day works best for you to attend a meeting? (Choose all that apply.)
*
Mornings
Afternoon
Evenings
Can you serve an an advisor for at least ONE year?
*
Please Select
Yes
No
Do you have any experience as an advisor, volunteer or public speaker? Please describe:
Why are YOU in interested in being a patient|family advisor at St. Anthony Regional Hospital?
Can you describe specific things healthcare professionals at St. Anthony Regional Hospital have done to help you or your loved ones?
*
Can you describe specific things healthcare professionals at St. Anthony Regional Hospital can do differently to be more helpful to you or your loved ones?
*
What positive improvements to patient care would you like to see as a result of your involvement with the Patient|Family Advisory Committee?
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