Please ensure that you have reviewed the Southlake Website -- www.southlakeregional.org/ Patient & Family Advisory Program before completing the volunteer application.
Please complete all areas of the application. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
Fields marked with an * asterisk are required fields. If you do not wish to submit your application, you may exit this form at any time by closing your browser. All information will be lost.

Patient & Family Advisor Volunteer Application

Personal Information
First Name*
Preferred name
Last Name*
Home Address
City
Province
Postal Code
Home Phone*
Work phone
Extension
Cell Phone
E-mail Address*
Are you currently a Volunteer at Southlake Regional Health Centre?
Yes
No
Languages Spoken in additon to English

In the past two years have you or a member of your family, partner or chosen support person been an in- or out-patient at the Southlake Regional Health Centre?
Yes
No
If yes, Where?
What are your reasons in applying for a Patient and Family Advisor volunteer position at Southlake Regional Health Centre?
How did you hear about volunteering at Southlake Regional Health Centre? (Check all that apply)
Other
Availability
Hospital meetings usually occur within the hours of 7 a.m. to 9 p.m. Please indicate ALL times when you are available to attend meetings.
Monday
Morning
Afternoon
Evening
Tuesday
Morning
Afternoon
Evening
Wednesday
Morning
Afternoon
Evening
Thursday
Morning
Afternoon
Evening
Friday
Morning
Afternoon
Evening
Volunteer Opportunities
In what capacity would you like to volunteer as a Patient & Family Advisor?
Community Awareness Committee
Corporate Patient & Family Advisory Council
Program Level Patient & Family Advisory Council
Is there a specific Program Level Patient & Family Advisory Council that you would like to join? Please indicate.
Committee or Working Group
Is there a specific Committee or Working Group that you would like to join? Please indicate.

Please read and check the following:
I understand that submitting this application and/or being interviewed does not guarantee a position as a Patient & Family Advisor
I understand that, upon acceptance of this position, Southlake requires that I submit the following documents prior to commencing my duties as a Patient & Family Advisor:
Vulnerable Sector Police Check

Results of a negative 2-step Tuberculosis (TB) Test

Proof of current immunization

A signed confidentiality/security agreement

1 reference


Southlake thanks you for your interest in Patient and Family Advisor volunteer position.

The personal information contained in this application is collected pursuant to the Public Hospital Act and the Freedom of Information and Protection of Privacy Act (FIPPA), and will be used for the purpose of the Patient and Family Advisor selection and placement processes at Southlake. This information wil not otherwise be shared without permission from the applicant/guardian.

Due to the fluctuations in our requirements for volunteers and the suitability of applicants, we cannot guarantee that every appplicant will obtain a volunteer placement.

THANK YOU FOR YOUR INTEREST IN VOLUNTEERING AT SOUTHLAKE!