Client and Family Partner Application Form

Do you consent to sharing your contact information with Baycrest and the Client and Family Partner Committee Chair for a brief telephone interview, if necessary
Yes No 

The following questions will allow us to begin to get to know you.

2. Are you a...
 Patient/Resident Family member of a patient/resident Live in the community

3. When was your care experience at Baycrest? (Check all that apply.)
 2016 to current year 2015 2014 2013 or before

4. What language(s) do you speak?

5. Have you volunteered at Baycrest in any capacity within the past two years?
 Yes No

6. We recognize that our Client and Family Partners have busy lives. How much time are you able to commit to being a client and family partner? (Check one)
 Less than 5 hours per month 5 to 8 hours per month Up to 10 hours per month More than 10 hours per month

7. Are you available to serve as a Partner for at least 2 years? (You can still be considered to become a Partner if you answer "no.")
 Yes No

8. How would you like to help? I want to: (Check all your interest areas)
 Help develop or review informational materials for clients and family members. Help improve patient safety. Help improve the client and family role in care decision making. Help improve the hospital facilities/design. Help recruit and orientate hospital staff and clinicians. Review and provide input to improve Baycrest policies and procedures. Provide the clients/families voice/perspective on committees.

Please tell us about yourself.

9. What are your skills/experience/interest:

10. To the extent possible, our Client and Family Partners will reflect the diversity of the clients and families serve. Please share anything about yourself that you think would add to the diversity of our team of partners.