CHA Patient & Family Advisory Council (PFAC)              New Member Application
To apply to join CHA's PFAC as a member please complete the application below.
Name (Last, First, Middle) *
Pronouns *
City *
State *
Zip code *
Preferred Phone *
Is this a home or cell phone? *
Email address *
I am a *
Are you currently a CHA employee? *
Are you able to commit to participating in one (weekday) evening meeting per month? *
Are you comfortable speaking openly in a large group? *
Are you able to commit to membership on the Council for at least one year? *
Languages you speak *
Our Patient & Family Advisory Council reflects the diversity of the patients and families we serve. Please share anything about yourself that you think would add to the diversity of our team of advisors. Please consider diversity to be any of the following or more: ethnic, racial, spiritual, social, economic, educational, geographical, gender, sexual orientation, unique family structure, disability, chronic illness, single parent, full-time parent, grandparent, student, etc. *
Please tell us about your experience receiving care at Cambridge Health Alliance *
Please tell us why you would like to be a member of our Patient and Family Advisory Council *
How did you learn about CHA PFAC? *
Do you require any special accommodations in order to participate in meetings (e.g. handicap access, food allergies, language interpreter)? *
I certify that all statements on this application are true and complete. I understand that the selection as a PFAC member is contingent upon CORI check.  I agree to abide by the guidelines of the Council, to respect patient confidentiality, and to uphold CHA values of Community, Integrity, Respect, Compassion, Learning and Excellence.  I understand that as a Patient & Family Advisory Council member, I am making a commitment to attend one meeting per month for my accepted term. If selected for PFAC membership, I understand that any falsification of, or omission from this application may result in termination of such membership. *
Signature (type name) *
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