Patient & Family Advisory Council Application
Name
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First Name
Last Name
E-mail
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Phone Number
*
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Area Code
Phone Number
Cell Number
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Area Code
Phone Number
Work Number
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Area Code
Phone Number
What's the best way for us to contact you? (Choose one)
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Home
Cell
Work
Email
Languages you speak:
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Please check the following boxes as appropriate.
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I am a patient.
I am a family member of a patient.
What Church Health services do you or your family use?
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Primary care clinic
Walk-in clinic
Specialist Provider clinic
Dental clinic
Church Health YMCA
Optometry clinic
Physical therapy
Behavioral health clinic
MEMPHIS Plan/ Healthcare Advisory Team
The Well (Child Life)
Health coaching
Cooking classes
Creative Movement Studio programs (Pilates, yoga, etc.)
Please specify times when you are able to attend meetings.
Mondays:
7-8 a.m.
8-9 a.m.
9-10 a.m.
10-11 a.m.
11 a.m.-12 p.m.
12-1 p.m.
1-2 p.m.
2-3 p.m.
3-4 p.m.
4-5 p.m.
5-6 p.m.
6-7 p.m.
Tuesdays:
7-8 a.m.
8-9 a.m.
9-10 a.m.
10-11 a.m.
11 a.m.-12 p.m.
12-1 p.m.
1-2 p.m.
2-3 p.m.
3-4 p.m.
4-5 p.m.
5-6 p.m.
6-7 p.m.
Wednesdays:
7-8 a.m.
8-9 a.m.
9-10 a.m.
10-11 a.m.
11 a.m.-12 p.m.
12-1 p.m.
1-2 p.m.
2-3 p.m.
3-4 p.m.
4-5 p.m.
5-6 p.m.
6-7 p.m.
Thursdays:
7-8 a.m.
8-9 a.m.
9-10 a.m.
10-11 a.m.
11 a.m.-12 p.m.
12-1 p.m.
1-2 p.m.
2-3 p.m.
3-4 p.m.
4-5 p.m.
5-6 p.m.
6-7 p.m.
Fridays:
7-8 a.m.
8-9 a.m.
9-10 a.m.
10-11 a.m.
11 a.m.-12 p.m.
12-1 p.m.
1-2 p.m.
2-3 p.m.
3-4 p.m.
4-5 p.m.
5-6 p.m.
6-7 p.m.
Why would you like to serve on our Patient & Family Advisory Council?
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Do you have any special skills? (ie. Microsoft office proficiency, experience in healthcare or customer service, graphic design, creative writing, photography, etc.)
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Submit
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