Guelph Community Health Centre - Client Advisory Committee Application

The Guelph Community Health Centre (Guelph CHC) sees clients as experts in their own experience. We are working with them to improve the quality, safety and experience of their care.

Guelph CHC’s goal is to reduce barriers to health care. The Client Advisory Committee (CAC) members will help us do this by sharing their wisdom gained through lived experience. Members will also share their knowledge of community needs and their personal use of Guelph CHC’s programs and services. This will include insight into community trends and system wide barriers faced by Guelph CHC’s clients. During the CAC meetings, you are only expected to share experiences that you feel comfortable with.

Guelph CHC will uphold all privacy and confidentiality policies and procedures. The information on this form will only be shared with the CAC coordinator.

Please ask Guelph Staff for support if needed.

This form will take about 10 minutes to complete. Your participation is voluntary.

Your responses are anonymous and confidential. Your answers will not affect your ability to access the programs/services at the Guelph Community Health Centre.

We appreciate and value your time in completing this form. We are only able to accept a set number of CAC members. We will contact everyone who applies by September 11th. You will either be offered a spot on the committee or we will suggest another volunteer role that may be better fitted.

Thank you for taking the time to complete this form.

For more information please contact:

Kate Vsetula, Director of Community and Organizational Development
Guelph CHC, 176 Wyndham Street North, Guelph ON N1H 8N9
519-821-6638 x335
kvsetula@guelphchc.ca

Question Title

* 1. Please complete your contact information

First and Last Name

Preferred Name

Preferred Pronoun

Phone Number

Email Address

Preferred way to be contacted

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* 2. The CAC will help Guelph CHC make decisions by giving advice to the Board of Directors, management and staff. We are looking for a wide range of personal experiences and viewpoints so we can best reflect the community that we serve.

Check all of the boxes that describe you.

I am a client

I am a caregiver

I am a family member of a client

I am a Guelph CHC or SEED volunteer

I am 18 years of age or older

English is my second language

I need the support of a translator

I am BIPOC (Black, Indigenous, Person of Colour)

I am LGBTQ2+

I am a New Canadian

Other (please specify)

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* 3. Please tell us what program(s) you use at the Guelph Community Health Centre?

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* 4. CAC members are people (or caregivers, family members of clients) who access Guelph CHC programs and services.

Which Guelph Community Health Centre location(s) do you or the person you support, go to for your programs? Check all that apply.

Downtown Guelph

Shelldale

Grange Hill East Neighbourhood Program

Brant Neighbourhood Program

Two Rivers Neighbourhood Program

EarlyON Children's Centre at Stone Rd. Mall

Other (please specify)

Question Title

* 5. The Guelph CHC Vision is a community without barriers to health and wellbeing.

Describe barriers you may have. We will work with you to make being part of the CAC as barrier free as possible. Check all that apply.

Transportation

Joining a meeting online

Joining a meeting on the phone

Childcare

Other (please specify)

Guelph Community Health Centre - Client Advisory Committee Application

Question Title

* 1. Please complete your contact information

Question Title

* 2. The CAC will help Guelph CHC make decisions by giving advice to the Board of Directors, management and staff. We are looking for a wide range of personal experiences and viewpoints so we can best reflect the community that we serve.

Check all of the boxes that describe you.

Question Title

* 3. Please tell us what program(s) you use at the Guelph Community Health Centre?

Question Title

* 4. CAC members are people (or caregivers, family members of clients) who access Guelph CHC programs and services.

Which Guelph Community Health Centre location(s) do you or the person you support, go to for your programs? Check all that apply.

Question Title

* 5. The Guelph CHC Vision is a community without barriers to health and wellbeing.

Describe barriers you may have. We will work with you to make being part of the CAC as barrier free as possible. Check all that apply.

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* 6. Describe past committee experience, community work or volunteering that you have done. (Past committee experience is welcomed but not required.)

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* 7. How did you find out about this opportunity?

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* 8. Which Guelph CHC staff do you work with most?

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* 9. Please share anything else you would like about yourself or this opportunity.

Guelph Community Health Centre - Client Advisory Committee Application

Question Title

* 1. Please complete your contact information

Question Title

* 2. The CAC will help Guelph CHC make decisions by giving advice to the Board of Directors, management and staff. We are looking for a wide range of personal experiences and viewpoints so we can best reflect the community that we serve.Check all of the boxes that describe you.

Question Title

* 3. Please tell us what program(s) you use at the Guelph Community Health Centre?

Question Title

* 4. CAC members are people (or caregivers, family members of clients) who access Guelph CHC programs and services. Which Guelph Community Health Centre location(s) do you or the person you support, go to for your programs? Check all that apply.

Question Title

* 5. The Guelph CHC Vision is a community without barriers to health and wellbeing. Describe barriers you may have. We will work with you to make being part of the CAC as barrier free as possible. Check all that apply.

Question Title

* 6. Describe past committee experience, community work or volunteering that you have done. (Past committee experience is welcomed but not required.)

Question Title

* 7. How did you find out about this opportunity?

Question Title

* 8. Which Guelph CHC staff do you work with most?

Question Title

* 9. Please share anything else you would like about yourself or this opportunity.

* 2. The CAC will help Guelph CHC make decisions by giving advice to the Board of Directors, management and staff. We are looking for a wide range of personal experiences and viewpoints so we can best reflect the community that we serve.

Check all of the boxes that describe you.

* 4. CAC members are people (or caregivers, family members of clients) who access Guelph CHC programs and services.

Which Guelph Community Health Centre location(s) do you or the person you support, go to for your programs? Check all that apply.

* 5. The Guelph CHC Vision is a community without barriers to health and wellbeing.

Describe barriers you may have. We will work with you to make being part of the CAC as barrier free as possible. Check all that apply.