Call to find a provider
1-800-833-3100

Family Advisory Council Nomination Form

When nominating a parent or guardian for the Children's Family Advisory Council, please provide detailed answers to the questions on this nomination form. This information will be used to select council members. In order to recruit a council that represents families of different backgrounds and medical specialties, we are not able to accept every nominee.

Please consider the following attributes when making your nomination. Council members should:

  • Share insights and information about their experiences in an educational way.
  • See beyond their personal experiences.
  • Respect the perspectives of others.
  • Have a positive outlook on life and a sense of humor.
  • Feel comfortable speaking in a small group setting.
  • Be willing to share their child's medical experiences on behalf of Children's.
 
* Name of Person Submitting Nomination:
* Email Address:
* Best Contact Telephone Number (with Area Code):

Nominee Information

* Parent/Guardian's Name:
Best Contact Telephone Number:
Address 1:
Address 2:
City:
State
Zip Code:
* Patient's Name:
* Patient's Age:
Child's Diagnosis or Condition:

What strenghts or attributes would this parent/guardian bring to the Children's Family Advisory Council:

Is there any additional information you would like to provide?: