Home Site Map HPHA Intranet Contact Us Privacy Policy
You are Here : Home    Volunteers, Foundations & Patient Partners    Patient Partners     Application
 
<October 2018>
SMTWTFS
123456
78910111213
14151617181920
21222324252627
28293031
20/10/2018
Health Care Heroes Radiothon!
Tune in to CKNX AM920, FM 101.7 or FM 94.5 and donate to the Clinton Public Hospital Foundation or the Seaforth Community Hospital Foundation! You can also join the Seaforth Community Hospital at Maplewood Manor between 9 am and 4 pm for entertainment, a silent auction, BBQ and other events!
23/10/2018
Blood Donor Clinic - Stratford
1:00 pm to 7:00 pm / Rotary Complex
Men have more blood than women. Men have 1.5 gallons versus 0.875 gallons for women.
Volunteers
Foundations
Patient Partners
Patient Partner Opportunities
Application
Meet Our Patient Partners
Contact Information

Application

At HPHA we recognize the importance of partnering with our patients and families to meet the needs and priorities of the communities we serve. If you are interested in applying you may do so by completing the form below or accessing the print version: Patient Partner Application Form

Printed applications can be dropped off at your nearest HPHA hospital site at the Switchboard / Reception area for internal mailing.  You may also mail your application form to the address listed below.

Attention: Patient Experience Office - Huron Perth Healthcare Alliance
46 General Hospital Drive
Stratford, ON N5A 2Y5

 

Online Application



Thank you for your interest in joining The Huron Perth Healthcare Alliance (HPHA) as a Patient Partner.
 
7
 
7
* First Name
 
1 1
* Last Name:
 
1 1
Mailing Address:
 
5
* Preferred Method of Contact:
 
 Telephone    Email Address:  

8 1
 
7
* Have you been a patient, family member or caregiver of a patient at HPHA within the past two years?
 
 Yes
 No

3 1
 
7
* If yes, please tell us a little about your experience including the hospital locations(s) and departments where care was provided.
 
5 1
 
7
* Why would you like to serve as a patient partner?
 
5 1
What areas, hospital programs or issues are you interested in?
 
 Committee Membership
 Project Participation
 Patient Experience Surveying
 Sharing Your Story

3
Other:
 
5
 
7
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

3
 
7
Other
 
5
 
7
Please read and check before submitting
 
7
I understand that by submitting this application and/or being interviewed does not guarantee a position as a Patient Partner.
 
7
*
 
2 1
Applicants Signature: (signature is not required if completing application on line)
 
1
Date:
 
6
 
7
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).
 
7