1.Please provide your contact information:

Name

Address

Address 2

City/Town

State/Province

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code

Email Address

Phone Number

2.What is your preferred contact method?

Email

Phone

Text

Mail

3.How would you describe yourself? (Check all that apply)

White

Black or African American

Hispanic or Latino

Other (please specify)

4.What is your age?

18-24

25-34

35-44

45-54

55-64

65+

5.What is your gender?

Female

Male

Other (specify)

6.What is your occupation? (If retired, what is your background?)

Thank you for taking the time to complete this application for the ACMH Hospital Patient and Family Advisory Council. Please provide brief, descriptive answers to the following questions.

7.Why are you interested in joining the Patient and Family Advisory Council?

8.What are some of the things you would like ACMH Hospital to do differently to better help patients and their families?

9.What are some of the specific things that healthcare professionals at ACMH Hospital do/have done to help you or your family?

10.Are there certain topics or areas of the organization in which you have a special interest?

11.Please outline one activity that you participated in as a team member - such as a sport, community event or work-related activity - and how you view your contribution to achieve effective teamwork.

12.What positive improvements to patient care would you like to see as a result of your participation in the Patient & Family Advisory Council?

13.Is there anything else you would like to add?