Thank you for your interest in VON's Advisors Program. Please tell us a little bit about yourself.

We will use the information you provide below to contact you about opportunities to participate in VON’s Client and Family Engagement Program. VON respects your privacy and will not sell, rent, or share your information with others. For more information, please read our privacy policy.

Please do not include any personal health information belonging to yourself or any other person in your responses.

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* 1. First Name

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* 2. Last Name

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* 3. Phone Number

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* 4. Email Address

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* 5. Where did you or your loved one receive VON services?

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* 6. Postal Code (First three digits only) 

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* 7. What are your areas of interest?

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* 8. Do you have experience of providing input as a Client and Family Advisor at any healthcare organization?

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* 9. If you have experience as an Advisor, please share your experience and its impact on you.

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* 10. Why are you interested in becoming an Advisor at VON?

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* 11. In your opinion, do you or your loved one have any unique needs or perspectives that you would like represented in the health care services?

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* 12. Do you self-identify as belonging to a group that has faced disadvantages within the health care system? (e.g. language, race, disability, gender etc.?)

By clicking “Submit Responses” you consent to VON collecting and using the information you have provided to contact you about participation opportunities with VON’s Client and Family Engagement Program.
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