Patient/Family Advisory Committee Membership Application

Conditions of Volunteer Services. Please read before submitting application.

I certify that the statements made in this application are true and correct and have been given voluntarily. I understand that I will not be paid for my services as a volunteer member of the Patient/Family Advisory Committee. I agree to abide by the guidelines of the Volunteer Services, to respect patient confidentiality and to uphold the traditions and standards of Edward-Elmhurst Health. I understand that membership on the Patient/Family Advisory Committee will be based upon approval from the Patient/Family Advisory Committee steering committee and Committee Chair. Staff will choose volunteers they feel are best suited for the Advisory Committee based on interviews and group needs. Volunteers will demonstrate a readiness to help others, maintain respect for collaboration and assist in delivering quality care to all Edward-Elmhurst patients. I understand that by signing this application, I am authorizing the staff of the Advisory Committee to review my visit history and dates of service.

I understand that membership on the Committee requires my commitment to attend monthly Committee meetings.

For those applying as a family member: To assure compliance with Federal regulations, family members must include the patient's name and obtain his or her signature to indicate that he or she understands you may use his or her name and medical history in your capacity as Committee member. If the applicant is the parent of a minor child, the patient's signature is not necessary.