Patient & Family Advisory Council Recruitment Form

PFAC Member Application

Please complete the information below. Thank you for your interest in helping improve the patient and family experience.
Name(Required)

Connection to Our Organization

I am applying as:(Required)
Area(s) of care experience
(Leadership, Community engagement, engaged student)

Meeting Participation & Commitment

I am comfortable sharing my ideas in a group setting.
I can provide respectful, constructive feedback.
I can commit to attending meetings (1 hour meeting each month).
I can commit to a 2-year term.

Information to Support Diverse Representation

Community
(example: Mayo, University of Kansas, etc.)

References

Full Name
Full Name

Consent

Clear Signature
Date
If selected your PFAC application will be forward to Volunteer Services to complete onboarding.