Hospice Advisory Council Application
Name
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First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Time Preferred
AM
PM
Emergency Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship
*
Back
Next
Have you EVER been convicted of a crime, plead guilty, nolo contender (no contest) or had adjudication withheld?
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Yes
No
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:
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Yes
No
Please check all that apply: I have a prior connection to:
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Empath Hospice
Suncoast Hospice
Suncoast Hospice of Hillsborough
Tidewell Hospice
Please check all that apply: I was related to an Empath Health hospice patient as a
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Spouse/significant other
Close Friend
Other
Please tell us what year you last experienced services from Empath Health*
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Please tell us why you are interested in joining the Patient and Family Advisory Council:
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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:*
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Are you comfortable speaking in a group setting?
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Yes
No
What are some things the staff did or said that made your family’s hospice experience easier for you?
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What are some things the staff did or said that made your hospice experience more difficult?
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MoveDuplicateSettingsDeletePlease describe any special skills, interests or experiences you feel could be valuable to your work as a Family Advisor with us:
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Date
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Month
-
Day
Year
Date
Submit
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