First Name *

Last Name *

Age range *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Primary Phone Number *

Secondary Phone Number

What is the best time to receive calls?

Email *

Is English the language you primarily use when communicating? *

Are you available to attend the meetings (at least 10 meetings a year for 1-2 hours, can be virtual or in person)? *

Have you or a loved one ever been hospitalized at UofL Health? *

Which facility were you or your loved one hospitalized (if multiple, please choose the council you are interested in serving as advisor for)? *

Please share anything about yourself that you think would add to the diversity of our council including special interests or experiences. *

Why would you like to be on the Patient & Family Advisory Council? *

What areas of concern do you have that you would like to see the Patient & Family Advisory Council address? *

Signature *

*Acknowledgement form of confidentiality to be signed upon approval of membership

PFAC Application

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