Rx Outreach Patient Advisory Board

Rx Outreach Patient Advisory Board

Application Form
Patient Advisory Board Application

Thank you for your interest in joining the Patient Advisory Board! We value your lived experience and perspective. This application should take about 15-20 minutes to complete. There are no "right" or "wrong" answers—we want to understand your unique story and what you'd bring to the board.

Application Deadline: August 31, 2026

What to Expect:
- 3 virtual meetings per year.
  - First meeting to be held October 27, 2026 from 1 - 3 pm CST. Future meetings scheduled with Advisory Board members.
- $75 stipend per meeting attended
- Child care and technology support
- No healthcare background required
SECTION A: Contact Information
Name:
Preferred Name (if different):
Pronouns (optional):
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Email:
example@example.com
Preferred Contact Method: (Check one)
SECTION B: Background Information
1. Age Range (Check one - this helps us ensure diverse representation)
2. What best describes where you live?
3. How did you hear about this opportunity?

Other
SECTION C: Your Experience
4. Have you personally experienced challenges accessing medications you or a family member needed? (Check all that apply)

Other
5. Have you used Rx Outreach services?

Other
SECTION D: Your Perspective
6. What perspective or experience would you bring to the Patient Advisory Board? (Consider your background, community, age, health journey, cultural perspective, or anything else that shapes how you see medication access)
7. Why do you want to serve on the Patient Advisory Board?
SECTION E: Participation
8. The Patient Advisory Board meets three times per year via video conference (Zoom or similar) for about 2 hours per meeting. Can you commit to this schedule?
9. Between meetings, we may occasionally (1-3 times per year) ask for quick feedback via email or brief surveys. This typically takes 15-30 minutes. Is this manageable for you?
SECTION F: Additional Information
10. Is there anything else you'd like us to know about you or your interest in the Patient Advisory Board?
Should be Empty:

Rx Outreach Patient Advisory Board

SECTION A: Contact Information

SECTION B: Background Information

SECTION C: Your Experience

SECTION D: Your Perspective

SECTION E: Participation

SECTION F: Additional Information