Patient/Family Advisory Council Application 
Thank you for your interest in joining the Strawberry Wilderness Community Clinic Patient Family Advisory Council. Please fill out the form to apply. 
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Full Name 
Date of Birth 
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Address
Phone Number
Email
Why are you interested in joining the Strawberry Wilderness Community Clinic Patient Family Advisory Council?  *
Have you or any of your family members been a patient at Strawberry Wilderness Community Clinic?
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If yes, how was you or your family members experience?
Do you participate in other committees or boards of directors?
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If yes, which ones? 
Are you able to make a commitment to attending monthly meetings?
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What special interests or experiences would you like to offer to the council?
Do you require any special accommodations in order to participate at the meeting (e.g. handicap access, food allergies, language interpreter)?
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If yes, please describe.
Are there any other specific concerns you'd like to see this group discuss? 
What else would you like us to know about you? 
I agree to abide by the guidelines of the Council, to respect patient confidentiality, and to uphold the traditions and values of Strawberry Wilderness Community Clinic and Blue Mountain Hospital District. I understand that membership on the Patient and Family Advisory Council will be based upon approval by the PFAC Committee. I understand that as a Patient and Family Advisory Council member, I am making a commitment to attend one meeting per month for my accepted term. (Please Initial)
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