Apply - Kadlec Patient and Family Advisory Council

Contact Information

We will never sell your information, and will only use this information for the purposes of the Kadlec Patient & Family Advisory Council.

First name*

Last name*

Email*

Phone*

999-999-9999

Address

Street address*

Address line 2

City*

State*

Postal / Zip code*

Country*

Preferred method of contact*

Email

Phone

Mail

About your experience

How recent was your last visit or experience with Kadlec?*

Estimate days, months, years, etc.

How have you been connected with Kadlec in the past?*

Patient

Family member or friend of a patient

Employee

Volunteer

Check all that apply.

Being on the Counsil

What is your primary interest in participating in our council?*

How would you describe your communication style?*

Commitment expectations

This is a passionate group of people who come together to affect positive change within the Kadlec system. Please understand that if you are selected as a member, a serious commitment is needed.

The council meets for two hours on the first Friday of the month. Are you able to meet consistently?*

Yes

No

Project time varies between two and four hours monthly. Can you participate in additional projects?*

Yes

No