Headwaters Health Care Centre - Become a Patient Family Advisor

I understand that submitting this application and/or being interviewed does not guarantee a position as a Headwaters Patient & Family Advisor
I understand that, prior to starting in my role as a Patient & Family Advisor, I would be required to submit the results of a vulnerable sector search (18+ years old), sign a Headwaters Confidentiality Agreement and pledge to support the Headwaters Values:
I understand that, as a Patient & Family Advisor, I would be accountable to the Quality Committee of the Board:
I declare the above information to be true and complete to the best of my knowledge. I understand that a false statement may disqualify me or lead to my exit as a Patient & Family Advisor:

First Name:
Last Name:
Preferred Name:
Address:
City:
Postal Code:
Phone (Best number to reach you on during the day):
Alternative Phone Number:
Email:
Preferred Method of Contact:	TelephoneEmail
Are you a (select one):
Can you speak English? (select one):	YesNo
What other languages do you speak?:
Do you have lived experience at Headwaters in the past 3 years?:	Yes No Other "Lived experience" means that either you were a patient, family member or caregiver to a Headwaters patient.
What area of care are you interested (select all that apply):	Allied Health Ambulatory Care Communications Critical Care Diagnostic Imaging Dialysis Diversity, Equity & Inclusion Emergency Department Facilities Infection Prevention and Control Medicine Mental Health Obstetrics Oncology Patient Relations Pediatrics Professional Practice (policy review) Project Management Spiritual Care Surgery Volunteers
Other (please state):
Are you comfortable sharing your lived experience with the Patient & Family Advisory Partnership and/or other project/program groups in order to learn from that experience and make improvements? (select one):	YesNo
Are you currently a volunteer at Headwaters? (select one):	YesNo
Do you have access to a computer and email? (select one):	YesNo
Have you participated in any patient and family engagement activities in the past? (select one):	YesNo
Are you currently or have you ever been involved in a legal challenge between you/your family and a hospital? (select one):	YesNo
If yes, please provide details:
Why would you like to become a Patient & Family Advisor?:
Please tell us how your lived experience/interest could be helpful to improve our services and the experience of others?:
Please specify the time when you are most available to attend group meetings, be involved in projects/committees:	Daytime (7am-5pm): Evening (5-9pm): Weekends
Methods:	In person: Teleconference:
How did you hear about the Patient & Family Advisory role/opportunity? (select one):
Please confirm that you understand and agree with the following:	I understand that submitting this application and/or being interviewed does not guarantee a position as a Headwaters Patient & Family Advisor I understand that, prior to starting in my role as a Patient & Family Advisor, I would be required to submit the results of a vulnerable sector search (18+ years old), sign a Headwaters Confidentiality Agreement and pledge to support the Headwaters Values: I understand that, as a Patient & Family Advisor, I would be accountable to the Quality Committee of the Board: I declare the above information to be true and complete to the best of my knowledge. I understand that a false statement may disqualify me or lead to my exit as a Patient & Family Advisor: By completing and submitting this form, you are providing a digital signature.
Date:	Today
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