Family Advisory Board Family Advisory Board Membership Application

First Name      

Last Name             

Home Phone   

Work Phone      

Email Address   

Date of Birth      

Address             

 

Application Information


Please briefly describe your experience with Children's Mercy

Why are you interested in becoming more involved with Children's Mercy?

Do you have improvements or ideas you would want to bring to Children's Mercy?

  

 If yes, please briefly explain

 

 

What are the names of your children who were cared for at Children's Mercy? What clinics, units, and/or physicians did they receive care from?


Name 

Clinic/Unit/Physician 

Name 

Clinic/Unit/Physician 

May we contact the clinics, units, and/or physicians who have cared for your child or children?

  

Please note that the information you enter into this form will be held in the strictest of confidence and will not be used or disseminated for any purpose other than as a tool to determine membership eligibility.

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