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

Contact information

Emergency contact

In the event of an emergency whom should we notify?

1. Patient or Family Hospital Experience:

Please tell us why you are interested in becoming a member of this council.

2. Hospitalization:

Have you or your family member been hospitalized or have received outpatient/Emergency Services at Elmhurst Memorial Hospital?
If yes, how long ago?

3. Please describe in detail.

Was there something that you would have liked your healthcare professional(s) to have done to have made your visit more comfortable/favorable?

4. Council:

What special interests or experiences would you bring to the council? (Community/Church group membership, leadership skills, special training, and other volunteer activities)

5. Commitment:

As a member of the Patient Family Advisory Council you would need to commit to one evening meeting a month and to assist in a special event once a year. Would you be able to make this commitment?

6. Special Interests:

I have a special interest in the following areas: (such as Emergency Care, Cancer Care, Cardiac, Rehabilitation, Complimentary Therapies, Health Education etc.) Why does this interest you?

7. Additional Comments:

What was most memorable about your experience at Elmhurst Memorial Hospital?

8. Other interests

Are you interested in becoming a hospital volunteer?