Children's Family Engagement Opportunities Interest Form

Children's Family Engagement Opportunities Interest Form
Please use this form to express interest in joining our Family Advisory Council, Friends of Family Advisory Council or Youth Advisory Council.

Please note: All of our family engagement opportunities have eligibility criteria. Information provided in this form will be used to review interest and determine eligibility for membership. Submission of an interest form does not guarantee acceptance into any family engagement opportunities.

If you have questions, please reach out to TheFamilyVoice@choa.org

Thank you for your time and we look forward to hearing from you!
What council are you interested in?*

Family Advisory Council (FAC)Friends of Family Advisory CouncilYouth Advisory Council (YAC)
Information about you
Name*

First NameLast Name
I am a:*

Current patientFormer patientParent/Legal guardian/Primary caregiverCommunity member (not a family member)
Thank you for your interest. To be eligible for one of our family engagement opportunities, you must be a current patient, past patient or parent/primary caregiver of a Children’s patient who has received services from Children’s within the last three years. If you have questions, please send an email to TheFamilyVoice@choa.org
Preferred email address*
example@example.com
Preferred phone number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your age?*

13-1718-2425-3435-4445-5455-6465 or above
Your care experiences
Have you/your child received care at Children’s Healthcare of Atlanta in the past three years?*

YesNo
Thank you for your interest. To be eligible for one of our family engagement opportunities, you or your child must have received services from Children’s within the past three years. If you have questions about family engagement opportunities, please send an email to TheFamilyVoice@choa.org.
Select all of the Children's services you or your child have had experience with.*

Behavioral and Mental HealthEmergency DepartmentInpatient Care (Overnight Stays)Marcus Autism CenterOutpatient SurgeryRadiology (MRI, X-Ray, CT, etc.)Specialty Care Clinic (Ex: Diabetes, ENT, Neurology, Orthopedics, etc.)Urgent CareOther
Your involvement
Briefly tell us why you are interested in joining one of our advisory councils.*
How did you hear about this opportunity?*
Is there additional information you would like to share?
Should be Empty:

Children's Family Engagement Opportunities Interest Form

Information about you

Your care experiences

Your involvement