Application
Date: ________________
Name: __________________________________________________________________________________
Mailing Address ___________________________________________________________________________
Street: ___________________________________________________________________________________
City: __________________________________ State: ________ ZIP Code: ________________
Home Telephone: ________________________ E-mail Address: ______________________________
1. What is your preferred way of receiving communication about the council?
___ E-mail ___ Regular Mail
2. Is it okay to share your contact information (address, telephone number, and E-mail address) with other members of the council?
___ Yes ___ No
3. Have you received care at a clinic or hospital for which this council is being
formed?
___ Yes ___ No
3a. If Yes, at which clinic or hospital did you receive care? ____________________________________
4. Do you have any dietary needs we should be aware of (i.e. vegetarian)?
___ Yes ___ No
If Yes, please elaborate. ____________________________________________
5. Do you have any special needs we should be aware of?
___ Yes ___ No
If Yes, please elaborate. ____________________________________________
6. Why would you like to be on the council?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
7. What issues would you like to see the council address?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
8. What special interest or experiences would you like to offer to the council?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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