WYR OHT - Western York Region Ontario Health TeamWestern York Region OHT Patient and Family Advisory Council

Thank you for your interest in participating in the Western York Region OHT Patient and Family Advisory Council. All information contained on this form is considered confidential and is intended for the purpose of selection and placement related to the Patient and Family Advisory Council opportunities only.

If you are unable to complete the online form, a PDF version can be downloaded here.

Western York Region OHT Patient and Family Advisory Council Application Form

"*" indicates required fields

Name*

First Last

City*

Phone*

Email*

What is the best way to contact you?*

Phone

Both

What is the best time of day to contact you?*

Have you, your family or someone you provider care for, received services from a health care provider in Western York Region (King, Vaughan or Richmond Hill) within the past 2 years?*

Yes

Please tell us why you are interested in joining the Patient and Family Advisory Council for the Western York Region OHT.*

Please share any additional information you would like us to know.

Please review and check the following before submitting:*

I understand that submitting this application and/or being interviewed does not guarantee a position as a Patient and Family Advisor for the Western York Region OHT.

I understand that prior to joining the Patient and Family Advisory Council for the Western York Region OHT, I am required to complete and submit a Vulnerable Sector Screening Check (VSSC) Report and demonstrate a satisfactory result.

I understand that as a condition of representing the Western York Region OHT as a Patient and Family Advisor, I am required to submit proof of full COVID-19 vaccination.

Western York Region OHT Patient and Family Advisory Council – Application Form

Western York Region OHT Patient and Family Advisory Council Application Form