|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:|
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