Application Form - Patient Experience Partner - Vitalité | Francophone leader serving its communities

Zone *

Facility *

Full Name *

Telephone *

Cell *

Age group *

14 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 +

Address *

Postal code *

Email *

Are you part of a minority group? *

Yes

No

Spoken languages *

Frenc

English

Other

Written languages *

French

English

Other

Contact in case of emergency

Full Name *

Telephone *

References

Please provide the name, full address, and email address of two people from whom we could obtain a reference (individuals to whom you are not related and who have known you for at least two years).

Full Name *

Telephone *

Postal code *

Relationship *

Communication *

French

English

Full Name *

Telephone *

Postal code *

Relationship *

Communication *

French

English

Experience

Relevant information (training, education, work experience, etc.) *

Why do you want to become a patient experience partner? *

Which of the following programs/departments have you had experience with as a patient, family member or caregiver in the past three to five years? Place a check next to all answers that apply. *

Other

I certify that the information provided on this form is true and accurate.

N.B: Please note that we will only contact those whose profile matches the profiles sought for projects or committees.