Patient Experience Partner 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 Health?

Yes

No

Languages Spoken in addition to English

Emergency Contact Information

* Contact Name

Relationship

Home Phone

Work Phone

Extension

* Cell Phone

E-mail

In the past five years have you received care or supported someone receiving care at a hospital?

Yes

No

Please indicate which department(s)

Cancer Centre

Cardiac

Emergency Department

Maternal Child (e.g. Paediactrics,Birthing, NICU)

Surgery

Mental Health (e.g. Inpatient, Outpatient)

Medicine (e.g. Inpatient Cancer, ICU, Medical Complex Care)

Northern York South Simcoe Ontario Health Team

Other

What are your reasons in applying for a Patient Experience Partner volunteer position at Southlake Health?

How did you hear about volunteering at Southlake Health? (Check all that apply)

If you selected 'Other' please specify

Volunteer Opportunities

Patient Experience Partner Council (PXPC)- is a council of people made up of both patients, family members and staff members who partner to advise and support the strategic direction of Southlake in matters that relate to the patient and create an environment where the best expereinces happen at the corporate and clinical level.

Please confirm you are interested in:

Patient Experience Partner Council

Please read and check the following:

I understand that submitting this application and/or being interviewed does not guarantee a position as a Patient Experience Partner

I understand that, upon acceptance of this position, Southlake requires that I submit the following documents prior to commencing my duties as a Patient Experience Partner:

Vulnerable Sector Police Check

Results of a negative 2-step Tuberculosis (TB Test)
Proof of current immunizations
A signed confidentiality/security agreement
One Reference
Signed organization/volunteer agreement

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 will 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 applicant will obtain a volunteer placement.

THANK YOU FOR YOUR INTEREST IN VOLUNTEERING AT SOUTHLAKE!