Application

The North York Family Health Team would like to thank you for your interest in our Virtual Patient Advisory Collaborative (VPAC). This advisory collaborative will help improve and enhance patient experiences at the NYFHT.
 
By submittng this application, you are agreeing to share your contact information with the NYFHT administrative staff and other members of the VPAC. This information will not otherwise be shared without your permission.
 
Please note, we cannot guarantee that every applicant will be selected to be a participant of the Virtual Patient Advisory Collaborative.
 
Thank you for your interest in supporting the North York Family Health Team in this advisory role.

Question Title

* 1. Your First and Last Name:

Question Title

* 2. I am a:

Question Title

* 3. Gender:

Question Title

* 4. Best phone number to reach you:

Question Title

* 5. Email address:

Question Title

* 6. Please select the age range that applies to you

Question Title

* 7. Highest level of education received

Language:

Question Title

* 8. Primary Language:

Question Title

* 9. Other Languages (Please list below):

Question Title

* 10. How do you feel you could support the NYFHT in improving patient care?

Question Title

* 11. Do you participate in any other community activities? Please list and describe

Question Title

* 12. Use the space below to write anything else about yourself that you would like us to know

T