Client and Family Partner Application Form Name: First and Last NameStreet Address: City: Province: Postal Code: Home Phone: Cell Phone: Email Address: Consent to share your contact information?: YesNo 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?Why do you want to become a Client and Family Partner?: Are you a: Patient/ResidentFamily member of a patient/residentLive in the community When was your care experience at Baycrest?: 2016 to current year201520142013 or before (Check all that apply.)What language(s) do you speak?: Have you volunteered at Baycrest in any capacity within the past two years?: YesNo 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?: Less than 5 hours per month5 to 8 hours per monthUp to 10 hours per monthMore than 10 hours per month (Select one)Are you available to serve as a Partner for at least 2 years? : YesNo (You can still be considered to become a Partner if you answer "no.")How would you like to help? I want to: Help develop or review informational materials for clients and family membersHelp improve patient safetyHelp improve the client and family role in care decision makingHelp improve the hospital facilities/designHelp recruit and orientate hospital staff and cliniciansReview and provide input to improve Baycrest policies and proceduresProvide the clients/families voice/perspective on committees (Check all your interest areas)What are your skills, experience, interest: Please share anything about yourself that you think would add to the diversity of our team of partners: To the extent possible, our Client and Family Partners will reflect the diversity of the clients and families serve.