Hospice Advisory Council Application

Have you EVER been convicted of a crime, plead guilty, nolo contender (no contest) or had adjudication withheld?
If YES, give dates, nature and final disposition of each:
A criminal conviction will be considered only as it applies to the volunteer position for which you are applying. The seriousness, nature of the offense, time lapsed, and rehabilitation will be taken into account.
Please indicate your willingness to share your contact information with other FAC/Organization members:
Please check all that apply: I have a prior connection to:
Please check all that apply: I was related to an Empath Health hospice patient as a
Please tell us what year you last experienced services from Empath Health*
Please tell us why you are interested in joining the Patient and Family Advisory Council:
Please describe any other committee experience you have had in the community e.g. through schools, faith based organizations, etc. and list the organizations and activities in which you have been active:*
Are you comfortable speaking in a group setting?
What are some things the staff did or said that made your family’s hospice experience easier for you?
What are some things the staff did or said that made your hospice experience more difficult?
MoveDuplicateSettingsDeletePlease describe any special skills, interests or experiences you feel could be valuable to your work as a Family Advisor with us:
Date

MonthDayYear
Date
Should be Empty: