Please complete this application form if you are interested in becoming a member of the Patient and Family Advisory Council at Our Lady of Lourdes Memorial Hospital. Once you complete the form, click the submit button at the bottom.

Name and address

First name:

Last name:

Title:

Permanent Address:

City:

State:

Zip:

Preferred phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Care received at Lourdes

Have you or a family member received care from any of Lourdes services within the past year?

Why would you like to be a member of the Council?

Special interests/experiences

What special interests or experiences would you like to offer the Council?

Other helpful information

We believe the Patient and Family Advisory Council should reflect the diversity of the population that Lourdes serves. In light of this, please share any information that you think would add to the diversity of our Council.

Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

What kinds of email would you like to receive?

Electronic newsletters
Allows the volunteer service department to send out mass emails regarding important information for volunteers.

Recruitment appeals

Mandatory Education

Volunteer Agreement

I understand that I am applying to serve in a volunteer capacity without contemplation of pay for the services I am providing.

I Agree