PFEC Application Form

PFEngagementCommittee
Name
Address
City
Province
Phone	ext.
Email

Preferred method of contact (please select):
Phone
Email

I am (please check):
A current patient
A former patient
A family member of a current patient
A family member of a former patient
An interested community member

When did you or your loved one receive care at Winchester District Memorial Hospital? (Please check all that apply)
2012-present
2010-2012
2008-2010
Before 2008
None of the above

What services did you or your loved one receive at Winchester District Memorial Hospital?
Emergency visit
Medical Hospitalization
Childbirth
Surgical Hospitalization
Clinic Visit
Rehabilitation
Diagnostic Imaging
Other (please specify)
Other (please specify)

I am interested in participating as a (please check all that apply):
Committee member
Occasional reviewer (working group)
One-time participant (focus group)
Sitting on a hospital committee (please indicate an area of interest)
Other (please describe)

Are you comfortable if we communicate with you (written and verbal) in English?:	Yes No

Why do you want to become a Patient and Family Advisor at Winchester District Memorial Hospital?
What do you think you could contribute as a Patient and Family Advisor?
Please describe any experience you may have as a member of a team or committee through work or volunteering in the community:
Salutation

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