Family Advisory Council Membership Application Form

Thank you for your interest in becoming a member of the Family Advisory Council.


Please fill out the following application completely. If you have any questions or need assistance, please contact FamilyAdvisoryCouncil-FL@nemours.org.


All information is confidential.

Contact Information

Caregiver

Phone
Phone

Emergency Contact

Phone
Phone
Phone

mm/dd/yyyy

Patient

mm/dd/yyy

Select or enter value
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Patient 2

mm/dd/yyyy

Patient 3

mm/dd/yyyy

Other Information

If yes, please share your experiences indicating the organization, duties and dates of service. If this will be your first time, write “first time.”

Post-Application Steps

After submitting this application, you will be required to complete the following:


  1. The onboarding team will contact you for a phone interview once the application is successfully submitted and determined to meet criteria.
  2. If granted membership, you must sign a Confidentiality Agreement and complete the FAC New Member Orientation.


Please note, submission of an application does not guarantee placement in the Council. If all membership spots are occupied, we will keep your application for when a spot is available in the future.

Acknowledgements


  • I certify that the statements made in this application are true and correct. I understand that giving any false information in this application, discovered before I start membership or while I am a member, can lead to my removal from the Family Advisory Council.


  • I authorize Nemours Children’s Health, and any agent acting on its behalf, to investigate all statements made in this application. I understand that this information may be shared with any party that has legal and proper interest, and I release Nemours Children’s Health from any legal responsibility whatsoever for supplying such information.


  • I understand that I will not be paid for my services now or in the future as this is strictly volunteer work.


  • I am not currently excluded, debarred, suspended or otherwise ineligible for participating in federally-funded health care programs, or subject of a process which could result in my exclusion, debarment or suspension from such programs.


  • Nemours Children’s Health is an equal opportunity employer. We do not discriminate in hiring with regard to race, color, gender, religion, creed, national origin, veteran’s status, military leave or other characteristics prohibited by applicable law.

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