Cancer Care PFAC Application


Name

Date of birth

Address

City

State

Zip code

Home phone

Work phone

Cell phone

Email

Languages you speak

Emergency contact name / Telephone

Current employment status





Times that are best for you to attend meetings






Have you received care from Covenant in the past?



Have you been an advocate for a relative or friend who received care at Covenant?



What type of cancer were you or your loved one diagnosed with?















Dates of your or your loved one's experience at Covenant (Check all that apply)




What cancer care services did you or your loved one use?













Check all boxes that apply in the areas you are interested in helping with.






Issues of special interest

Why would you like to serve as an advisor?

Describe your experience with Covenant.

I certify that the responses on this application are true to the best of my knowledge. I authorize Covenant HealthCare to do a criminal background check and understand my date of birth is necessary for this check. Misrepresentation of facts constitutes cause for separation from membership.

Signature date