Women's and Children's PFAC Application


Date of birth




Zip code

Home phone

Cell phone


Preferred Contact Method

Emergency contact name / telephone

If you selected "Other" for ethnicity, please specify here.

Times that are best for you to attend meetings

Have you received care at Covenant HealthCare?

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

The dates of my care experience at Covenant HealthCare include (Check all that apply)

What care services have you or your family member/friend used? (Check any that apply).

Note: We are looking to our Council members to have a diverse range of experience with Covenant HealthCare, and appreciate your sharing any information. Please be assured that this information is private and will be maintained as confidential.

If you selected "Other" above, please specify here.

If you selected "Issues of special interest" above, please specify here.

Why would you like to serve as an advisor?

If you have served as an advisor, been an active volunteer committee member, or done public speaking for other programs or organizations, please briefly describe this experience.

Tell us about your or your family's care experience at Covenant HealthCare. What would you have improved about this experience? What impressed you about this experience?

Is there anything that you would like us to know about you?

By signing this form, I agree that all above stated information is accurate and I consent to Covenant HealthCare conducting a background check to allow me to establish volunteer status with the organization.

Signature date