Online Submission Form for Patient Partner Council Volunteers

Patient Partner Council Membership Application

Thank you for your interest in this volunteer opportunity to participate as a member of the Patient Partner Council at Listowel Wingham Hospitals Alliance. Please complete and submit this form. Refer to the volunteer posting for more information about the council. After submission of this form, you will be contacted via email for next steps.
Name*
First Last
Email*
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Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please tell us why you would like to serve as a patient partner?*
Please describe some topics or issues that you are especially interested in.*
Do you have any special skills that you would be willing to share in your role as a member of the Patient Partner Council?*
Please read and acknowledge check boxes before submitting*
- I understand that submitting this application and/or being interviewed does not guarantee a position as a member of the Patient Partner Council (PPC).
- I understand that prior to beginning as a PPC member I must sign a confidentiality agreement.
- I understand attendance on-site requires proof of full COVID vaccination immunization status provided to Occupational Health. I may also join the meetings virtually if unable to attend on-site
- If completing patient facing activities, I understand I must obtain a vulnerable sector screening (police check) and complete an Occupational Health Clearance
Applicants who are selected for an interview will be contacted within 30 days of submission of the application form.

Personal information contained on this form is collected pursuant to the Public Hospitals Act and the Freedom of Information and Protection of Privacy Act (FIPPA), and will be used for the purpose of Patient Partner Council selection and placement at LWHA. We will not share this information otherwise without permission from the applicant / guardian.
Name
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Patient Partner Council Membership Application

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