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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 intended for the use by the Summa Health System Patient and Family Advisory Council only.

You will be contacted upon receipt 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.