Patient & Family Advisory Council Recruitment Form PFAC Member ApplicationPlease complete the information below. Thank you for your interest in helping improve the patient and family experience.Name(Required) First Last Preferred Name (Optional)Phone Number(Required)Email Address City/Community(Required)Connection to Our OrganizationI am applying as:(Required) Patient Family Member/Caregiver Both Area(s) of care experience Clinic/Ambulatory Emergency Inpatient Specialty Care Women and Children Approximate date(s) of care experience1. Please briefly describe your experience with our organization.2. What motivated you to apply for the PFAC?3. What do you think we do well for patients and families?4. What is one thing we could improve?5. What ideas do you have to improve the experience of patients and families?6. Describe a time you gave feedback or worked with others to improve something.7. What strengths, background, or perspective would you bring to the PFAC?(Leadership, Community engagement, engaged student) 8. Is there anything else you would like us to know as we consider your application?Meeting Participation & CommitmentI am comfortable sharing my ideas in a group setting. Yes Somewhat No I can provide respectful, constructive feedback. Yes No I can commit to attending meetings (1 hour meeting each month). Yes No I can commit to a 2-year term. Yes No Information to Support Diverse RepresentationLanguages spoken:Community Topeka Flint Hills Manhattan Emporia Other Consumer of another Organization(example: Mayo, University of Kansas, etc.)ReferencesFull Name First Last Preferred Name (Optional)Phone NumberEmail Address (Optional) Full Name First Last Preferred Name (Optional)Phone NumberEmail Address (Optional) ConsentIf selected, would you need any accommodation to participate fully?Applicant Signature:DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If selected your PFAC application will be forward to Volunteer Services to complete onboarding.