Advisory Council Application

Title:

Mr.

Ms.

Mrs.

Name*

First Last

Email Address:*

Address*

Street Address City Province Postal Code

Phone (home):*

Phone (work):

Phone (other):

Which area do you live in?

Why are you interested in participating in Concordia’s Patient & Family Advisory Committee?*

Are you involved with any groups or initiatives in your community? How would you describe your community?

What insights, experience, and perspectives do you feel that you would bring?

Please provide the names of two people who could be contacted as references.

Reference Name #1:

First Last

Reference Phone #1:

Reference Name #2:

First Last

Reference Phone #2:

Phone

This field is for validation purposes and should be left unchanged.

Patient & Family Advisory Council Application