Applicant Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you 18 years of age or older?
Yes
No
Highest Level of Education:
Some high school but did not graduate
High school graduate or GED
2-year college degree
4-year college degree
Greater than 4-year college degree
Occupation/Job Title:
Have you ever been part of a council or leadership group before?
Yes
No
If yes, please describe this experience and/or your role with that group:
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Please tell us about your experience(s) at St. Claire HealthCare.
Have you been a patient at St. Claire HealthCare in the last 2 years?
Yes
No
Has a friend or family member been a patient at St. Claire HealthCare in the last 2 years?
Yes
No
What did we do well?
What could we have done better?
Why do you want to be a St. Claire HealthCare Patient-Family Advisor?
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Next Steps
We will contact you by phone or email if you are selected for an on-site interview where our Patient Experience team will have the opportunity to learn more about you, your interests, and discuss the opportunity to become a member of the Patient-Family Advisor.
Conditions of Volunteer Services: (Please read before signing)
Upon designation as an advisor, you will be required to complete St. Claire HealthCare’s volunteer application and meet all necessary requirements including a criminal background check, submit immunization records, undergo HIPAA training, and sign a confidentiality agreement. If you are unable to fulfill these requirements, you will not be eligible to serve as a Patient-Family Advisor.
I certify that the statements made in this application are true, correct, and have been given voluntarily. I also understand that any false and/or misleading information may result in ineligibility to serve as a Patient-Family Advisor.
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