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Mazzoni Center's Community Advisory Board Interest Form

Hello! Thank you for your interest in being a member in one of Mazzoni Center's Community Advisory Boards (CAB). Community Advisory Boards are comprised of community members, including but not limited to current clients, who provide input and guidance on various projects, programs, and events that the organization is a part of. After filling out this interest form, a Community Health Engagement Coordinator will contact you via email or a phone call to follow up within a a few business days.
1.First and Last Name
chosen name is okay here, you do not need to write your legal name(Required.)
2.What are your pronouns?(Required.)
3.What is your age?(Required.)
4.Phone Number(Required.)
5.Email Address(Required.)
6.Please confirm your email address
(Required.)
7.Are you a patient or client of Mazzoni Center?(Required.)
8.If you are a patient with us, for how long and which services do you receive?
9.If you are not a patient with us, have you engaged with Mazzoni Center in any other way? (ex. seeing us table at an event, attending a workshop or event of ours, etc.)
10.What do you want to share about your personal identities?
Example: I am South Asian, abled bodied, I am a trans-woman and queer, I was born and raised in Philadelphia, and I am HIV+
Only share what you feel comfortable(Required.)
11.Why are you interested in joining the Community Advisory Board?(Required.)
12.Do you have any barriers to attending in-person meetings?(Required.)
13.What day(s) of the week would you be able to attend CAB meetings? Check all that apply.(Required.)
14.What time(s) of day are you available to attend in-person CAB meetings? Check all that apply. (Required.)
15.What strengths or skills would you bring to the CAB?(Required.)
16.What problems are you passionate about solving that have an impact on quality of healthcare people receive at Mazzoni Center?(Required.)
17.If you have any accessibility needs, please share them here.
We hope to make this process and the CAB meetings as accessible as possible.
Thank you for filling out this survey and for your interest in participating in a Mazzoni Center CAB! You will hear from a Community Health Engagement Coordinator in the next few business days to follow up.
Press the "Done" button below to submit your responses.