Fraser Northwest Primary Care Community & Patient Advisory Committee Application
Fraser Northwest includes the municipalities of New Westminster, Coquitlam, Port Coquitlam, Port Moody, Belcarra and Anmore.  The Fraser Northwest (FNW) Community and Patient Advisory Committee (PAC) acts as a resource to: 

  • advise the Fraser Northwest Collaborative Services Committee (CSC) and Fraser Northwest Primary Care Network (PCN); 

  • work in partnership to include diverse, autonomous, and authentic voices of patients and agencies supporting patients in the Fraser Northwest; and 

  • advocate for patients as active collaborators in the role.

Its membership is volunteer based and a reflection of the community voices with lived experiences.


Sign in to Google to save your progress. Learn more
Email *
First Name: *
Last Name: *
Preferred Name:
Email Address:
Phone Number:
Home Address: 
We may at times request to send you something (e.g., thank you card, materials) by mail.
Year of Birth:
This is used for demographic purposes, we do not share your birth year. Youth under the age of 18 will be sent a parent/guardian consent form before participating.
Are you a member of any of the following groups? Please check all that apply.

We ask this to help us plan program activities and work towards PAC membership being representative of the FNW population. That is important because patient partners inform and influence the design and delivery of health care services, which need to be safe and accessible for everyone. We will not share this information about you with anyone, without your prior consent. We do share aggregate demographic information about general PAC membership.
I am:
To increase inclusiveness and respect please self identify as you feel comfortable. Non-binary person is an umbrella term used to describe gender identities beyond the binary male/female framework.
Clear selection
Is there anything else about your gender identity that you would like us to know?
The pronoun(s) I use are:
Because gender identity is an internal characteristic that should not be assumed, we ask what pronouns you would like to be addressed as.
Clear selection
How did you hear about the Community and Patient Advisory Committee?

Please let us know and if you were referred by a specific organization or group, we would love to know who they are
Clear selection
What interests you about the Fraser Northwest Community and Patient Advisory Committee?
What do you hope to gain from your involvement in the Network?
Are there specific areas of the health care system that you are most interested in getting involved in? Please select all that apply.
If you selected other, please describe
Do you have any accessibility requirements that you would like us to be aware of?
Have you ever worked in health care before?
Clear selection
Is there anything else about yourself that you would like to share? Do you have any final questions?
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Fraser Northwest Division of Family Practice. Report Abuse
Google Forms