Patient / Caregiver Partnership Council Application

Today's date *:

E-mail:

County:

Carson

Douglas

Lyon

Storey

Other

I am the

Patient

Spouse

Caretaker

Parent

Other

Within the past two years, have you or a loved one received care at any of the following Carson Tahoe services? Please check all that apply.

Primary or Specialty Care

Hospital stay or surgery

Emergency Department

Urgent Care

Outpatient Services (labs, imaging, therapy)

Other programs or services

If other, please list:

Recent Work Experience:

Education:

1. Why are you interested in becoming a Partnership Council Member?

2. If you have volunteered or participated in any organizations or committees, please share some examples (these may include work, community, or church activities).

3. Describe your experience, positive or negative, as a patient and/or loved one at Carson Tahoe Health.

4. The attributes of a good Partnership Council member include being a good listener, having excellent communication skills, working collaboratively, and maintaining confidentiality. Do you believe you have these attributes and why?

5. What special interests, experiences, talents would you offer the Partnership Council and/or how does your voice uniquely represent the community?

6. In-person meetings are held bi-monthly on the second Wednesday from 3:00–4:30 PM. Are you able to attend during this time?

Yes

No

7. Council members frequently communicate via email and work with Word, Excel, and PowerPoint documents. Are you comfortable sending and receiving files in these formats?

Yes

No

8. How did you hear about the Council?

Hospital staff or provider

Hospital newsletter or email

Social media (Facebook, Instagram, etc.)

Website

Friend or family member

Community event

Other

If other, please specify:

Anti-Spam Verification

Partnership Council Application

What Happens Once We Receive Your Application?