Youth Patient and Family Advisory Council

Please note: Parents may assist their children with filling in this application form. To recruit a diverse group of adolescents for the committee, we are unable to accept every applicant.

  • YOUTH ADVISOR PERSONAL INFORMATION

  • To help us get to know you better, please complete the following questions:

    • 1. Are you a…
    • 2. What language(s) do you speak?
    • 3. When was your or your family member’s care experience at this hospital? (Check all that apply)
    • 4. Do you currently have a parent in the Patient and Family Advisory Council (PFAC)?
    • 7. Have you received any of the following vaccines? (Check all that is applicable)
    • 8. If you have not been vaccinated with the above, would you be willing to take the required vaccinations?
    • 9. Are you able to commit to attending meetings on weekdays or weekends)? (It is essential that you attend meetings if you are to become a member of the Youth Advisory Council)
    • 10. We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor? (Check one)
    • If yes, what times would work best for you? (Select all that apply)
    • 11. Is there anything in your personal experience you would like to declare that might conflict with your participation in the Youth Patient Family Advisory Council?

  • PARENT(S)/GUARDIAN(S) INFORMATION

  • EMERGENCY CONTACT INFORMATION

  • PARENT/GUARDIAN CONSENT (if under 18 years of age)

  • has my permission to participate in the Youth Advisory Council at Sidra Medicine. I understand that my son/daughter is responsible for getting him/herself to and from meetings.

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    Youth Patient and Family Advisory Council Agreement Form

  • Please tick the following statements, indicating that you have read and understood the youth advisory expectations of members:

  • By signing below, I acknowledge and agree to the terms listed above: