Springfield Patient and Family Advisory Council Application * Required Fields Date * Example Format: MM/DD/YYYY Name * Home Address * Daytime Phone Number * Best Day/Time to Call * Email Address * I am a * Check all that apply Patient Family Member Community Member Volunteer CoxHealth Employee Tell us about your hospital experience(s) * What would have improved the experience? What impressed you about your experience? Why do you want to be involved in the Patient and Family Advisory Council? * If you have participated in any organizations or committees, please share some examples about it * Was it a successful committee? Describe some of the challenges you faced and how you dealt with them. What would you do differently? Tell us a little about yourself * leave this field blank to prove your humanity