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<June 2018>
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26/06/2018
Blood Donor Clinic - Stratford
1:00 pm to 7:00 pm / Rotary Complex
27/06/2018
Blood Donor Clinic - Goderich
5:00 pm to 8:00 pm / Knights of Columbus Hall
Families and other partners in care are welcome 24 hours a day according to patient preference, condition and care needs. Please check with unit staff about optimal visiting times for the patient.
Volunteers
Foundations
Patient Partners - How to Join HPHA

Patient Partner Application Form




Thank you for your interest in joining The Huron Perth Healthcare Alliance (HPHA) as a Patient Partner.
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* First Name
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* Last Name:
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Mailing Address:
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* Preferred Method of Contact:  Telephone  
 Email Address:  

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* Have you been a patient, family member or caregiver of a patient at HPHA within the past two years?  Yes
 No

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* If yes, please tell us a little about your experience including the hospital locations(s) and departments where care was provided.
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* Why would you like to serve as a patient partner?
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What areas, hospital programs or issues are you interested in?  Committee Membership
 Project Participation
 Patient Experience Surveying
 Sharing Your Story

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Other:
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We recognize that our patient partners have busy lives; Please let us know how much time you may be able to commit (Approximately) - please check one:  1-2 hours/month
 3-4 hours/month
 more than 4 hours/month

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Other
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Please read and check before submitting
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I understand that by submitting this application and/or being interviewed does not guarantee a position as a Patient Partner.
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*
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Applicants Signature: (signature is not required if completing application on line)
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Date:
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We will use personal information on this form to select and place Patient Partners at the Huron Perth Healthcare Alliance. We will not use the information in any other way without the permission from the applicant/guardian. We will protect your personal information, following the rules set out in the Public Hospitals Act and the Freedom of Information and Protection of Privacy Act (FIPPA).
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