PFAC Membership Application

PFAC Membership Application

Apply to join the Patient Family Advisory Council at Pershing Health System. Please complete all sections below.
Full Name

First NameMiddle NameLast Name
Street Address
City, State, Zip
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please briefly describe your experience with Pershing Health System
Why are you interested in becoming more involved in Pershing Health System?
Do you have any improvements/ideas you would want to bring to Pershing Health System?
If so, please briefly explain
Loved One 1 Name

First NameMiddle NameLast Name
Loved One 1 Clinic/Unit/Physician
Loved One 2 Name

First NameMiddle NameLast Name
Loved One 2 Clinic/Unit/Physician
May we contact the clinics, units and/or physicians who have cared for your loved one?
Would you be able to commit to attending 4-6 meetings per year at Pershing Health System?
As a member of Pershing Health System PFAC, I understand that communication between members is essential. Given this, I understand my name, address, phone number and email address will be provided to all Pershing Health System PFAC members.

Please note that the information you enter this form will be held in the strictest of confidence and will not be used or disseminated for any purpose other than as a tool to determine membership eligibility. Your application will be reviewed, and you will be provided with a response as quickly as possible. Thank you for your interest.
Acknowledgment
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: