Huron Perth Healthcare Alliance - Patient Partner Application Form

HPHA Patient & Caregiver Partner Application Form

*First Name:

*Last Name:

*Telephone Number:

ext.

Email Address:

*Mailing Address:

*City:

*Postal Code:

Preferred Method of Contact:

Preferred Method of Contact

Telephone

Email

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

At which HPHA hospital site did you or a family member receive medical care?:

*Which unit or department did you or your family member receive care? :

*Tell us why you would like to partner with HPHA :

*What Patient & Caregiver Partner Engagement Speciality are you interested in?:

What Patient & Caregiver Partner Engagement Speciality are you interested in?

Communications - Co-Writing, reading and reviewing organizational guidelines, brochures, pamphlets, patient information, policies, practices & procedures. Level of Commitment: partner flexibility, virtual participation

Operations - 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 a special interest in any specific health topics? :

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 & Caregiver Partner Application Form

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