Patient and Family Advisor Application Form Patient and Family Advisor Application Form Name* First Last Address* Street Address Address Line 2 City Province Postal Code Home Phone*Cell PhoneEmail Preferred contact* Home phone Cell phone Email Best time to call* Morning Afternoon Evening The following questions will help us get to know you better1. Are you a…* Patient/person with stroke Family member of a patient/ person with stroke 2. When did you or your family member have a stroke?* less than a year 1 - 3 years ago 4 - 5 years ago 6 - 10 years ago more than 10 years ago 3. How much time are you able to commit to being a patient or family advisor?* Less than 1 hour per month 1 to 3 hours per month 4 to 5 hours per month Other (please specify): 4. How long are you able to serve as an advisor?* Less than 1 year 1 to 2 years More than 2 years 5. Most meetings take place between 9am to 4pm. Please specify the times when you are able to attend meetings:* Daytime Evenings Between* Between* 6. How do you want to help as an advisor? I am interested in: (check all areas of interest)* Serving as a member of the Patient and Family Advisory Committee Participating on short term working groups Helping to develop or review education resources Providing feedback on and helping to improve programs and clinical practices Attending focus groups or sharing your stroke experience with health care providers or others Speaking at health care or community events Providing peer support to others who have had a stroke through our Peers Fostering Hope program If you have further questions, please contact moc.ekortsotnull@ofni. Personal information contained on this form is collected pursuant to the Public Hospitals Act and the Freedom of Information and Protection of Privacy Act and will be used for the purpose of the Patient and Family Experience Advisory selection and placement for the Toronto Stroke Networks. We will not share this information otherwise without permission from the applicant/guardian.