R.S.V.P to Our First Nuvance Health LGBTQIA+ Patient and Family Advisory Council Meeting

We hope you can join us for our first Health, Equity and Diversity LGBTQIA+ focused patient and family advisory council meeting on Wednesday, September 8, 2022 at noon. This meeting will take place online via Microsoft Teams. If you are interested in serving on this council, please note, you will need to register as a volunteer. Once you sign up, you will be contacted by a member of the Volunteer Services team with a link to the meeting. Please be sure to keep your new user ID and password in a safe place as you will need to refer to it in the future when logging in as a volunteer. Anything in yellow must be filled in.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Where are you applying to volunteer?

* First name

Preferred Name (If Different From First Name)

Middle name

* Family/last name

Name suffix

Gender

Pronoun - Subjective ('She', 'He', 'They', 'Ze')

Pronoun - Objective ('Her', 'Him', ''Them', 'Hir/Zir')

Pronoun - Possessive ('Her', 'His', 'Their')

Pronoun - Reflexive ('Herself', 'Himself', 'Themself', 'Hirself'/'Zirself')

* Phone (Home)

Phone (Mobile)

* Address

Address 2

* City

State

* Zip/postal

Tell Us More

How did you hear about volunteer opportunities at Nuvance Health?

* Please tell us why you feel you should be selected to participate in our program as a patient and family advisor; what you hope to learn from this experience, and highlight what others would say makes you unique. In addition, please answer the following questions:1.    Please tell us about yourself- what are your interests and skills? 2.    Why did you or why do you want to join a patient family advisory committee? 3.    What areas of improvement in our hospital do you think you could help us improve and how? 4.    What service care areas are you most interested in? Examples could be, Emergency care, Cancer care, behavioral health, Cardiac Care, Nuero Sciences or others. 5.    What do you hope to gain most from being a member of our PFAC? 6.    Please describe your best healthcare experience. 7.    Please describe your worst healthcare experience - what changes could you imagine yourself helping to identify and change as a PFAC member?

Final Steps

Please download and print form. Sign with either blue or black ink pen, then scan file to your computer and upload below
1. HIPAA Form. Please click here to download.

2. Multimedia Consent Form. Please click here to download.

* HIPAA Form

* Multimedia Consent Form

I certify that the information in this application is correct to the best of my knowledge. I authorize the investigation of all matters contained in this application and agree that any misleading or false statements shall be cause for rejection of this application and will be cause for immediate dismissal.

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