PFAC Application Form - Memorial Health System

Personal Information:

Name *

First

Last

Email *

Phone *

Preferred Method of Contact: *

Email
Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you willing to share your contact information with other PFAC members? *

Yes
No

Emergency Contact:

Name *

First

Last

Phone *

Email *

Personal Reference

All applicants are requested to submit at least one reference. Please provide complete information for a personal reference that has known you for a minimum of two (2) years.

Name *

First

Last

Email *

patient has and

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Meeting Availability

Meetings will occur on a bi-monthly basis for approximately 1 ½ - 2 hours.

What day works best for you?

Monday
Tuesday
Wednesday
Thursday

What time of day works best for you?

Mornings
Over Lunch
Afternoons
No Preference

History and Experience:

Briefly explain why you are interested in becoming more involved in the patient- and family-centered care at Memorial Hospital. *

Please describe any other committee experience that you have had either in schools, community, churches, Memorial Health System, etc? *

What has your and/or your family’s experience been when a patient at Memorial Hospital? *

Your Signature

Clear Signature

Date Signed

Thank you for the time you have taken to answer the questions above. If you have any questions, suggestions, etc., please feel free to contact: Sara Boyd, MHS Senior Director of Operations PFAC Co-Chairman Memorial Health System 511 NE 10th St. Abilene, Kansas 67410 785-263-6869