Patient and Family Advisory Council Membership Application Form

Thank you for your interest in our Patient and Family Advisory Council (PFAC) at Clearview Cancer Institute. 

The first step for consideration to join our advisory council at Clearview Cancer Institute is to complete the application form below.  Once you complete the form, please make sure to click the continue button. 

Thank you for your consideration,

-Rebekah Ormond, Volunteer Coordinator 

Contact Information:

Please let us know your full name.
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Please let us know your email address.

Demographic Information

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Diagnosis

Please let us know your message.

References

References may not be members of your family or individuals with whom you reside.

First Reference

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Second Reference

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Emergency Contact

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Areas of Interest and Experience

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YOUR RESOURCES

Cancer Treatment

UNDERSTAND TREATMENT OPTIONS

YOUR RESOURCES

Clinical Trials

REVOLUTIONIZING CANCER CARE

YOUR RESOURCES

Lung Screening

WHY SCREENING SAVES LIVES