Patient Experience Partner Volunteer Application

Volunteer Opportunities

A Patient Experience Partner is a volunteer who provides advice from the perspective of the patient, family, caregiver, or chosen support person to contribute to creating an environment where positive experiences contribute to better patient health outcomes. PXPs collaborate with Southlake's interprofessional team on councils, committees, working groups, or special projects, ensuring that patient care services are continuously improved.

Please confirm you are interested in:

Patient Experience Partner Council

Personal Information/About You

* First Name*

Preferred name

* Last Name*

Pronouns (optional)

Home Address

* City

Province

Postal Code

* Preferred phone number

Extension

Alternate phone number

* 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 Southlake Health?

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)

Other

Why are you interested in becoming a Patient Experience Partner at Southlake Health, and what do you hope to contribute as part of this role?

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

If you selected 'Other' please specify

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

If accepted to the Patient Experience Partner Program, you will be required to complete the following onboarding requirements:

Vulnerable Sector check (VSC)
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 the Patient Experience Partner 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 Experience Partner selection and placement processes at Southlake. This information will not otherwise be shared without permission from the applicant/guardian.

Your application will be reviewed by the Patient Experience Office to determine your eligibility for the program. You will receive communication regarding your application status within two weeks of submitting an application.

THANK YOU FOR YOUR INTEREST IN VOLUNTEERING AT SOUTHLAKE HEALTH!