Youth Patient and Family Advisory Council Registration

Age *

Grade and School *

Nationality *

Religion *

Address (city, zone, street no., House no.) *

Mobile no *

Email address *

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

3. When was your or your family member’s care experience at this hospital? (Check all that apply) *
202420232022202120202019201820172016

4. Do you currently have a parent in the Patient and Family Advisory Council (PFAC)? *
YesNo

6. What are the four reasons why you are interested in becoming a member of the Youth Advisory Council? *

7. Have you received any of the following vaccines? (Check all that apply) *
Tetanus, Diphtheria and Pertussis: TdapVaricellaHepatitis BMumps, Measles, and RubellaTuberculosis (TB)Other

8. If you have not been vaccinated with the above, would you be willing to take the required vaccinations? *
YesNo

9. Are you able to commit to attending meetings on weekdays or weekends? *
WeekdaysWeekends

10. How much time can you commit to being a patient and family advisor? (Check one) *
1 hour every other month1-2 hours every other month2-3 hours every other month

If yes, what times would work best for you? (Select all that apply)
AfternoonEveningOther

11. Do you have any personal experience that might conflict with your participation in the Youth Patient Family Advisory Council? *
YesNo

PARENT(S)/GUARDIAN(S) INFORMATION

Parent(s)/Guardian(s) Name(s) *

Mobile no *

Email address *

EMERGENCY CONTACT INFORMATION

Name(s) *

Mobile no *

Relationship *

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

Youth Advisor name *

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.

PARENT/GUARDIAN NAME *

Date *

Youth Patient and Family Advisory Council Agreement Form

Please tick the following statements to indicate that you understand the expectations of members:
I understand that I must be at least 10 years old. *
Attendance is mandatory for all meetings unless discussed with the PFAC liaison. *
I must respect and adhere to meeting timings. *
If I need to miss a meeting, I will inform the PFAC liaison. *
I will respect others’ differences and voice opinions respectfully. *
Using cell phones during meetings is prohibited. *

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

Member Name *

Date *

PARENT/GUARDIAN NAME *

Date *

Youth Patient and Family Advisory Council Registration

YOUTH ADVISOR PERSONAL INFORMATION

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

PARENT(S)/GUARDIAN(S) INFORMATION

EMERGENCY CONTACT INFORMATION

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

Youth Patient and Family Advisory Council Agreement Form

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

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