Community Member Application

Please complete the following form and share your information and interest in serving on a committee designed to maintain and improve the patient and family experiences at Mercy Hospital.

Employment Status
3. Which of the following program, departments or services have you or a loved one experienced at Mercy Hospital?
5. Would you be comfortable participating in a group where there could be suggestions or improvement opportunities about Mercy Hospital?

Authorization

I certify the statements made in this application are true and I understand the misrepresentation and/or withholding of information may result in the rejection of this application or my discharge if discovered after volunteer service begins. Current Mercy Hospital members will interview and choose volunteers they feel are best suited based on group consensus.

Before participating in the Mercy Hospital Patient and Family Advisory Council, an orientation will be provided and you will be asked to sign a confidentiality agreement.