ICSI Patient Advisory Council Application

ICSI believes that the Patient Advisory Council should reflect the cultural diversity of families who are consumers of our community/member ’s services. In this light, please share anything about yourself that you think would add to the diversity of our PAC. Please consider diversity to be any of the following or more: ethnic, racial, spiritual, social, economic, educational, geographic, gender, sexual orientation, unique family structure, disability related, chronic illness, single parent, full-time parent, grandparent raising child, etc.

*The following questions should be answered on a volunteer basis only and are designed to help us recruit a variety of talent.

At this time, we are not considering practicing health care professionals for PAC membership. However, we appreciate your interest and would like to consider you for other ICSI opportunities. If this is something you would like to pursue, please complete the application and we will contact you.

If you answered "yes" to question 1A, please select a response.

(first choice)

(second choice)

(third choice)

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