Patient and Family Advisory Council Membership Application

Company

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Name

First Last

Email

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Phone

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Choose from the following:

I am a patient/former Virginia Cancer Specialists patient.
I am a family member of a patient/former Virginia Cancer Specialists patient.

Tell us about your practice experience(s) - what would you have improved about the experience?

Tell us about your practice experience(s) - what impressed you about your experience?

If you have participated in any organizations or committees, please share examples (these examples may be from work, community, religous institution):

Is there anything else you would like us to know?

Please share with us a few sentences for why you are interested in joining:

Please select your age range:

18-25
26-34
34-44
45-54
55-64
65+

Please select what you identify as (select all that apply):

Male (he/him)
Female (she/her)
Transgender
Non-binary (they/them)
Prefer not to answer
Other

How would you describe your race and/or ethnicity? (select all that apply):

Black/African American
White/Caucasian
Asian American
Hispanic/Latino
Native American
Pacific Islander
Other
Prefer not to answer

Please select all languages you can speak fluently (select all that apply):? (select all that apply):

English
Spanish
Korean
Farsi
Arabic
Vietnamese
Chinese
Other

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Patient and Family Advisory Council Membership Application

Virginia Cancer Specialists Patient Family Advisory Council

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Award Winning Physicians