PFAC Membership Application
Please fill out the application below and press Submit Application.
Birthday (month/day only):
What's the best way to contact you?
How would you like to participate:
How often would you be available:
Every other Month
Have you, or a family member for whom you have provided care, used King's Daughters services?
Rate the quality of the care received
1 - Very Poor
2 - Poor
3 - Fair
4 - Good
5 - Very Good
Why are you interested in becoming a PFAC member?
Do you have special expertise to bring to the PFAC? For example, experience working with people with disabilities; an interest in healthcare disparity/equality; providing care for a elderly relative; computer technology, etc.
By completing the E-Sign below, I hereby consent and agree to all terms listed within the Confidentiality Agreement.
E-Signature (Check box to E-Sign)