NFAC Interest Survey
First Name
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Last Name
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Preferred Email Address
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City/Town that you live in
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State that you live in
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Primary Language
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Are you of Hispanic, Latino, or Spanish Descent?
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What is your race? Mark all that apply:
Please share with us any races not listed above that best describe you
Age
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Gender
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To volunteer at Boston Children’s you must agree to a background check, health screening and some vaccinations are required. Are you willing to submit this information?
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In the past 12 months, have you been a parent or caregiver of a patient at Boston Children's?
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Where have you/your child received care from Boston Children's (at any time)?
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Which departments have you/your child received care from at Boston Children's?
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What other departments/areas have you/your child received care from Boston Children's (at any time)?
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Within the past 12 months, how many times have you/your child received at Boston Children's (from any department)?
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Please tell us a little bit about why you are interested in joining the Neurosciences Family Advisory Council?
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Is there any other information you would like to provide?
Thank you for your interest in participating in the Neurosciences Family Advisory Council!
Thank you for your interest in participating in the Neurosciences Family Advisory Council!
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