Huron Perth Healthcare Alliance - Patient Partner Application Form

HPHA Patient Partner Application Form

*First Name:

*Last Name:

*Telephone Number:

ext.

Email Address:

*Mailing Address:

*City:

*Postal Code:

Preferred Method of Contact:

Preferred Method of ContactTelephoneEmail

*Please tell us why you would like to partner with HPHA and become a Patient & Caregiver Partner?:

*How did you hear about the HPHA Patient & Caregiver Partner Program?:

At which site(s) have you or a family member received medical care (please check all that apply):

*What was your involvement when coming to one of our HPHA sites? (please check all that apply)::

*Which unit(s) did you or your loved one receive care? (please check all that apply)::

*Please tell us about your healthcare journey experience:

*Please indicate the type of Patient & Caregiver Partner role that you wish to apply for:

Please indicate the type of Patient & Caregiver Partner role that you wish to apply forCommunications - Co-Writing, reading and reviewing organizational guidelines, brochures, pamphlets, patient information, policies, practices & procedures. Level of Commitment: partner flexibility, virtual participationOperations - Active members on hospital committees and councils etc. Level of Commitment: Commit to be an active participating member on a hospital committee/board/council. Frequent meetings Projects - Active participants in experience-based co-design initiatives and decision-making projects with care providers. Level of Commitment: commit to be an active participant on special projects, frequent meeting, may be a "one-time" commitment until completion of project

*Do you have experience working on projects or as a committee member?:

If yes, Please explain:

*Are there particular hospital areas or health topics that you have a special interest in? :

Please add anything else you wish to share about yourself (professional experience/skills, other volunteer work etc.):

I have access to a computer, tablet or smart phone

I understand that HPHA requires all Patient & Caregiver Partners & Volunteers to obtain a Vulnerable Sector Check (Police Check).

*All applications collected are kept private and confidential. The hospital is committed to accessibility for persons with disabilities. If you require assistance completing this application, please contact the Patient Experience Office at 519-272-8210 Ext. 2423.:

Patient Partner Application Form

HPHA Patient Partner Application Form

We are processing your submission.Please do not press back or refresh.

We are processing your submission.
Please do not press back or refresh.