Resize Text Search
  • Schedule an Appointment
  • Find a Doctor
  • Locations
Patient Information
Doctor Appointment
 
 
 

Application Form

Patient & Family Advisory Council Application Form

Please complete this form to be considered as a patient or family member candidate for the Summa Health System Patient and Family Advisory Council.

All information contained on this form is considered confidential and is inteneded for the use by the Summa Health System Patient and Family Advisory Council Selection Committee only.

You will be contacted upon reciept of this application form to participate in a phone or in-person interview. If selected, all advisory council members must participate in the Summa Health System orientation program

If you wish to fill out a paper application, please download it here. Fill out the form and return it to the address on the form.

Applicant Information
Additional Information: Thank you for taking the time to complete this application form. Please write brief but descriptive answers to the following questions in the spaces provided. Please know that this information will be kept confidential.
We would like to make it as easy as possible for you to attend. All advisory council meetings will be held on the Summa Akron City Hospital Campus Do you prefer:

Which day of the week do you prefer (check all that apply):