Application for Family Advisors

Application for Family Advisors

  • Name Name *
  • Address Address *
  • Home Phone Home Phone - -
  • Mobile Phone
    Mobile Phone
    - -
  • Fax Number: Fax Number: - -
  • Will you allow your contact information to be shared with other committee/advisory council members? *
    Will you allow your contact information to be shared with other committee/advisory council members?
  • My care was provided by (check all that apply): *
    My care was provided by (check all that apply):
  • The dates of my active experience at JHMI include (check all that apply): *
    The dates of my active experience at JHMI include (check all that apply):
  • Within the past TWO years, what care services has your family member used? (check all that apply) *
    Within the past TWO years, what care services has your family member used? (check all that apply)
  • Is there a healthcare professional with whom you would feel comfortable asking to support your nomination? *
    Is there a healthcare professional with whom you would feel comfortable asking to support your nomination?
  • If yes, may we contact them?
    If yes, may we contact them?
  • Phone Number: Phone Number: - -
  • CONFIDENTIALITY:

    All information contained in this form is considered confidential and is intended for use by the Johns Hopkins Children’s Center Family Advisory Council Membership Committee. The Committee will maintain appropriate and confidential handling of personal information as stated in HIPPA guidelines and is presented in volunteer training. Qualified applicants will be selected to participate in a face-to-face interview. If selected, all Family Advisory Council applicants must complete volunteer service requirements as assigned by the Volunteer Services department. These volunteer requirements include, but are not limited to the completion of the following: volunteer application, reference and criminal background check, volunteer orientation, HIPAA training and badge identification.

    All families served by the Johns Hopkins Children’s Center are welcome to apply for membership as a Family Advisor.

  • Draw or Type
    I understand this is a legal representation of my signature. Clear