* 1. Personal Information

* 2. Language(s) you speak:

* 3. Have you or a family member ever been employed in healthcare?

* 4. Are you a:

* 5. How did you hear about the Patient and Family Advisory Council?

* 6. Please choose times when you are available to attend meetings (check all that apply):

* 7. Within the last 12 months have you been a:

* 8. Your care provided at RAMC was primarily (check all that apply):

* 9. We believe our patient and family advisory partners should reflect the diversity of patients, families and friends who use our medical center. In light of this, please share some demographic information about yourself (optional):

* 10. What is your gender?

* 11. Which race/ethnicity best describes you? (Please choose only one.)

* 12. Why would you like to be on the Reedsburg Area Medical Center Patient and Family Advisory Council?

* 13. What special interest or experiences do you have to offer to the Council?

* 14. Please note any questions or concerns:

* 15. I understand that (checking all 4 boxes below indicates your agreement):

* 16. Please type your name for your electronic signature:

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