Patient and Family Advisory Council

Thank you for your interest in the Patient and Family Advisory Council at Covenant HealthCare! Please allow yourself approximately 15 minutes to accurately and thoroughly complete this volunteer application. If you have trouble completing this application, please contact Volunteer Services, 989.583.6040.

If you have previously volunteered for Covenant HealthCare, please contact us prior to submitting an application.

All Patient and Family Advisory Counsel members will be required to show proof of COVID-19 vaccine or complete a vaccine exemption form. After you complete your application, you will receive an email with information on how to submit proof of vaccination or begin the exemption process.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Applicant Information

* First name

* Family/last name

Preferred First Name

* Date of Birth

* Home address

* City

* State

* Zip Code

* Primary phone

Mobile phone

Work phone

* E-mail address

Gender

Race/Ethnicity (Optional)

Are you a veteran? (optional)

Emergency Contact Information

* Contact name

* Primary phone

E-mail address

* Relationship

Employment History

Have you ever worked or volunteered at Covenant HealthCare?

If yes, in what capacity and when?

Please list information for your two most recent employers.

Employer Name

Employer Address

Date of Employment

Job Title

Type of Work

Reason For Leaving

Employer Name

Employer Address

Date of Employment

Job Title

Type of Work

Reason for Leaving

Education

Highest Level of Education Completed

High School

City/State

College

Degree/Major

Other Professional Training:

Skills and Scheduling

Which PFAC are you interested in?

Have you or a family member recieved care at Covenant HealthCare or have you been an advocate for a relative or friend who received care within the past two years?

My care is/was provided by: (check all that apply)

* Please list any doctors or departments which provided care for you.

The dates of my care experience at Covenant HealthCare include: (check all that apply)

Within the past two years, what care services have you or your family member used? (check all that apply)

If you selected Other, in the question above, please describe here.

I would be interested in helping with: (identify all your interest areas)

* Why would you like to serve as an advisor?

If you have served as an advisor, been an active volunteer committee member, or done public speaking for other programs or organizations, please briefly describe this experience.

Tell us about you or your family's care experience at Covenant HealthCare. What would you have improved about this experience? What impressed you about this experience?

Is ther anything else you would like us to know related to your experiences at Covenant HealthCare?

Additional Information

Additional information or comments you would like to share with us prior to interview?

Have you ever been convicted of a crime, including a misdemeanor?

Are there any legal charges pending against you?

If yes (legal charges pending) please explain:

Are you volunteering to satisfy a court ordered probation?

If yes, please list probation officer's name and phone.

Authorization and Signature

* I certify that the responses on this application are true to the best of my knowledge. I agree that this information may be verified. I authorize Covenant HealthCare to perform all necessary background checks and understand my date of birth is necessary for these checks. If accepted for one of the Patient and Family Advisory Councils or any voluntary service, I will comply with the values, policies and procedures of Covenant HealthCare in effect or revisions which may be issued in the future.  Misrepresentation of facts constitutes cause for separation from volunteer placement. I understand that the position that I am applying for is an unpaid volunteer position.

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E-Signature