Family Advisory Council Application
Information About You
Name
*
First Name
Last Name
Email
*
example@example.com
Home phone
Please enter a valid phone number.
Work phone
Please enter a valid phone number.
Cell phone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name and age of each child
Information about your child
Name
First Name
Last Name
Condition or illness
Age
Age when treatment began
Has your child ever been hospitalized?
Yes
No
If yes, what year?
Where was your child admitted? (Name the department if known.)
Does your child go to an outpatient clinic?
Yes
No
If yes, which clinic(s)
Briefly tell us about your family's experience at Children's Healthcare of Atlanta
Why do you want to become a member of the FAC? Please include qualities that you think will make a great member of this Council
Submit
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