Application Form - Patient Experience Partner

Personal information
Contact in case of emergency
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).

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.

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