PFAC Advisor Application

Required fields are marked with an asterisk *.

Contact Information

First Name *

Last Name *

Middle Initial

Street Address *

Apartment/Unit #

City *

State *Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code *

Phone

Email *

Days/Times Available

Additional Information

Child's / Patient's Name (if applicable)

Are you willing to participate in monthly meetings? *Yes/noYesNo

If so, do you have transportation available?Yes/noYesNo

Have you ever worked for West Valley Medical Center? *Yes/noYesNo

If yes, when? What was your role?

Are you willing to share your contact information with the PFAC members? *Yes/noYesNo

I am the: *Select oneSpouseCaretakerPatientOther

I / 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/noYesNo

Do you have any dietary restrictions or food allergies? *Yes/noYesNo

Tell Us About You

Please tell us about you. Why are you interested in being a Patient & Family Advisor?

Rate Your Experience

Submit

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