PFAC Membership Application Question Title * 1. Personal Information: Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 2. What is your experience with Infinity Health I am a patient (current or former) I am a patient’s family member/support person Question Title * 3. The date of your Infinity Health patient experience was: Less than 6 months ago 6 months to one year ago 1-5 years ago Greater than 5 years ago Question Title * 4. The care received at Infinity Health was provided by: Behavioral Health Services Dental Health Services Pharmacy Medical Clinic Other (please specify) Question Title * 5. How did you hear about this opportunity? From the Infinity Health website Information was given to me by an Infinity Health employee PFAC brochure from Infinity Health I was invited to apply by a Infinity Health employee Other (please specify) Question Title * 6. Please tell us about your experience with our health center. What impressed you? Where could we improve? Question Title * 7. Please share any previous experiences you have had serving on a board or organizational committee (work, community, church, etc.): Question Title * 8. What interests you the most about the possibility of serving on the Patient Family Advisory Council? Question Title * 9. Please provide a brief description of what talents or strengths you would bring to the advisory council. Question Title * 10. Would you be able to commit to attending 6-8 meetings per year at Infinity Health? Yes, absolutely. I would definitely do my best to attend them all. I could probably only commit to 1 or 2. Question Title * 11. Are you a current/previous employee of Infinity Health? Current employee of Infinity Health Current Infinity Health board member Previous Infinity Health employee, but no longer employed there Previous board member None of the above Done