Family Advisory Council Membership Application Membership Application Name * Home Address * Town Zip Phone Number * Email Address * Preferred Method of Contact * Phone Email Best time to reach you? Relationship to Child(ren) * Parent Grandparent Guardian Sibling Other Relative Relationship to Child(ren) Have any of your children received care at Connecticut Children's? * Yes No When was the last time that they received care here? (ex. 01/01/2020) Which clinics or services have provided care to your children? Which Family Advisory Council (FAC) are you interested in joining? Organizational Cancer Care Diabetes Management Craniofacial NICU Behavioral Health Sickle Cell Care Languages Spoken English Spanish ASL OtherOther Based on your experiences at Connecticut Children's, are there certain topics you would like to see addressed by our FAC? Why do you want to join our FAC? * Submit Δ Thank you for your interest in the Connecticut Children’s Family Advisory Council! We will contact you by phone or email to discuss an interview and learn more about your interest in our FAC. In order to participate in our FAC, you will be required to pass a criminal background check, undergo HIPAA training and sign a confidentiality agreement. These will be discussed in detail during the interview process. If you have any questions regarding our Family Advisory Councils, please feel free to contact Susan Gilland, Assistant Manager – Patient & Family Experience at Call (860) 837-5582 or firstname.lastname@example.org.