Mountain States Health Alliance | Family Advisory Council Member Application Form

Niswonger Children’s Hospital
Family Advisory Council Member Application Form

Thank you for your interest in becoming a council member on the Niswonger Children’s Hospital Family Advisory Council. Please be assured that any information provided in this application is handled with the upmost confidence.

Name: *

Email Address: *

Street Address: *

City: *

State: *

Zip: *

Daytime Phone:

Evening Phone:

Cell Phone:

Which method is most convenient to contact you?

Daytime Phone
Evening Phone
Cell Phone
Email

Please describe your child's medical story:

We would also like to know which parts of the hospital you are familiar with.

How many total days has your child spent as an in-patient? *

How many times have you had clinic appointments? *

How many times have you visited the Emergency Room? *

Council members will be consulted for advice from different departments and units within the hospital. Please pick those departments or units with which you have had experience.

Emergency Room
Oncology
Surgery
NICU
PICU
Pediatric Unit
Other (please indicate)

Other:

Council members on the Family Advisory Council will collaborate with hospital staff on a regular basis. Please explain why you think parents and staff working together on different projects is beneficial.

Did you receive the Patient Admission Packet when you were admitted? Did this information assist you during your stay?

What types of information do you wish you had at the time of your stay?

How did you hear about the Family Advisory Council? (website; mailing; brochure or flyer in the hospital; staff member referral; fellow parent, etc.)

Hospital Recommendation
We would like to ask a hospital staff member to support your application.
Please give us the name of a doctor, nurse, child-life specialist, social worker,
or any other staff member who would recommend you.

Name of Staff Member: (If not a team member of Niswonger Children's Hospital or JCMC, please provide a phone/pager or email address) *

Phone/Pager:

Email Address:

Niswonger Children’s Hospital Family Advisory Council Member Application Form

Niswonger Children’s Hospital
Family Advisory Council Member Application Form