Required fields are marked with an asterisk *. Contact InformationFirst Name *Last Name *Middle InitialStreet Address *Apartment/Unit #City *State *Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *PhoneEmail *Days/Times AvailableAdditional InformationChild's / Patient's Name (if applicable)Are you willing to participate in monthly meetings? *Yes/noYesNoIf so, do you have transportation available?Yes/noYesNoHave you ever worked for West Valley Medical Center? *Yes/noYesNoIf yes, when? What was your role?Are you willing to share your contact information with the PFAC members? *Yes/noYesNoI am the: *Select oneSpouseCaretakerPatientOtherI / my child / family member has been treated most often in (select all that apply): *Emergency RoomIn-patient unitsOutpatient ClinicsOther areasFor windows: Hold down the control (ctrl) button to select multiple options.For Mac: Hold down the command button to select multiple options.If selected, are you willing to sign a confidentiality agreement and participate in PFAC orientation? *Yes/noYesNoDo you have any dietary restrictions or food allergies? *Yes/noYesNoTell Us About YouPlease tell us about you. Why are you interested in being a Patient & Family Advisor? Rate Your Experience Submit SuccessThe form was successfully sent. There was an error with the form submission.