Patient Partners Program Application

First Name *

Last Name *

Address *

Town/City *

Postal Code *

Telephone *

Alternate Telephone

Email Address *

What is the best way to contact you and what time of day? *

Have you, your family or someone you provide care for, received services from Mackenzie Health within the past 2 years? *

YesNo

In which department/unit(s) did you receive care?

Please review and check before submitting:

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

I understand that, upon acceptance as a member of the Patient Partners Program, Mackenzie Health requires that I submit the results of a criminal reference check with the vulnerable sector search (further details to be provided upon acceptance). *

I understand that prior to beginning work as a Patient Partner I must submit the results of a negative 2-step Tuberculosis (TB) test and provide proof of immunization. *

I understand that, prior to beginning work as a Patient Partner I must sign a confidentiality agreement. *

I understand that, as a Patient and Family Advisor, I will be accountable to the Executive Vice President, Chief Operating Officer and Chief Nursing Executive. *

What is your preferred employment status?

Thank you for your interest in participating in the Patient Partners Program. All information contained on this form is considered confidential and is intended for the purpose of selection and placement related to Patient Partners Program opportunities only.