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Expression of Interest Form

Preferred Method of Contact:
Can you speak English? (select one):
Do you have lived experience at Headwaters in the past 3 years?:

"Lived experience" means that either you were a patient, family member or caregiver to a Headwaters patient.
What area of care are you interested (select all that apply):

Are you comfortable sharing your lived experience with the Patient & Family Advisory Partnership and/or other project/program groups in order to learn from that experience and make improvements? (select one):
Are you currently a volunteer at Headwaters? (select one):
Do you have access to a computer and email? (select one):
Have you participated in any patient and family engagement activities in the past? (select one):
Are you currently or have you ever been involved in a legal challenge between you/your family and a hospital? (select one):
Please specify the time when you are most available to attend group meetings, be involved in projects/committees:


Please confirm that you understand and agree with the following:

By completing and submitting this form, you are providing a digital signature.