Advisor Application Form

Thank you for your interest in becoming a Patient and Family Advisor at West Parry Sound Health Centre (WPSHC). Improving the patient experience is a key priority for WPSHC. Patients and families have experience that can be invaluable in improving the care experience across the organization.

Please complete this form. Only selected applicants will be contacted for an interview.

Patient and Family Advisory Council Application Form

First Name(Required)

Last Name(Required)

Email(Required)

Home Phone

Work Phone

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is the best way to contact you and when?(Required)

When have you or a family member been a patient at WPSHC or a support person to a patient of WPSHC?(Required)

Why do you want to be a Patient and Family Advisor? Tell us about opportunities for improvement you have observed or what you feel WPSHC could do differently to better serve patients and families.(Required)

Please specify your availability to participate in meetings and events? (i.e. daytime, evening, weekend)(Required)

Are you willing to attend meetings via Zoom?(Required)

Do you require assistance with accessibility?(Required)

Please provide the name of a person who will provide a character reference for you.

Name(Required)

Phone(Required)

Email(Required)

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