Swedish Patient & Family Advisor Application Form

Name*

First
Last

Address*

Preferred Contact Method*

	Please Answer the following questions so that we may learn more about you:

Are you/were you a:*

	Swedish Patient
	Family Member of a Swedish Patient

At which Swedish clinic or campus would you be willing to participate as an advisor?*

Other, please specify

Have you or a family member received care at Swedish within the last five years?*

	YES
	NO

11.	What is the primary language spoken in your home?*

We recognize that our Patient and Family Advisors have busy lives. How much time are you able to commit to being a Patient and Family Advisor?*

We would ideally like our Advisors to serve for at least 1 year. How long would you be able to serve as an Advisor?*

	at least 1 year
	2 years or more