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 forSHARING - These patient & caregiver partners are engaged and given the opportunity to represent the voice of the patients by sharing their lived experience story in a safe environment. Level of Commitment: limited to scheduled events at the partners discretion.
CONSULTING - These patient and caregiver partners will be engaged to provide their feedback and input on the policies, programs and practices that shape the care and services at HPHA. Level of commitment: Ongoing or could be time limited to specific initiative.
COLLABORATING - These patients and caregiver partners will be engaged in specific project work and called upon as required to work with project leaders/teams. They will also be engaged as a member of specific hospital committees. Level of commitment: length of project / committee / council or at the partners discretion. Councils / Committees usually run 1-2 hours monthly or bi-monthly.

*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

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