Patient and Family Advisory Council Membership Application Form

The first step for consideration to join our advisory council at Clearview Cancer Institute is to complete the application form below. Once you complete the form, please make sure to click the continue button.

Thank you for your consideration,

-Rebekah Ormond, Volunteer Coordinator

Fields marked with an * are required

Contact Information

Full Name *

Nickname

Street Address *

City *

State *

Zip *

Home Phone *

Cell Phone

Email Address *

Demographic Information

Date of Birth *

Age *

Gender *

Female
Male

Education

I Am A (Please check one)

Patient
Family Member of a Patient
Caregiver of a Patient
Clearview Staff

Diagnosis

TYPE OF CANCER, STAGE, YEAR OF DIAGNOSIS, AND AGE OF DIAGNOSIS. (IF FAMILY MEMBER, PLEASE ENTER THEIR DIAGNOSIS.) *

References

References may not be members of your family or individuals with whom you reside.

References 1

Name *

Home Phone

Cell Phone

Relationship *

Have you ever been found guilty of a crime? *

Emergency Contact

Full Name *

Home Phone

Cell Phone

Relationship *

Areas of Interest and Experience

BRIEFLY TELL US WHY YOU ARE INTERESTED IN BECOMING A MEMBER OF OUR PATIENT AND FAMILY ADVISORY COUNCIL AT CLEARVIEW CANCER INSTITUTE. PLEASE INCLUDE ANY QUALITIES OR SPECIAL SKILLS YOU WILL BE ABLE TO CONTRIBUTE TO THE PROGRAM.

I CERTIFY THAT THE INFORMATION THAT IS PROVIDED ON THIS APPLICATION IS COMPLETE AND TRUE. I FURTHER ACKNOWLEDGE THAT FALSIFICATION OR OMISSION OF ANY SIGNIFICANT INFORMATION PRESENTED OR REQUESTED ON THIS APPLICATION OR DURING THE INTERVIEW PROCESS MAY RESULT IN REJECTION FOR A COUNCIL POSITION OR DISMISSAL. I HEREBY AUTHORIZE CLEARVIEW CANCER INSTITUTE TO REQUEST INFORMATION REGARDING MY APPLICATION FOR VOLUNTEER WORK FROM THE REFERENCES I PROVIDED. *

PLEASE CHECK THE BOX

Your Resources

Cancer
Treatment

UNDERSTAND TREATMENT OPTIONS

Your Resources

Clinical
Trials

Revolutionizing Cancer Care

Your Resources

Lung
Screening

Why Screening Saves Lives

Locations

Volunteer Opportunities