PFAC Membership Application
Please fill out the application below and press Submit Application.
First Name:
Last Name:
Email Address:
Street Address:
City:
State:
Zip:
Cell Phone:
Home Phone
(Optional)
:
Birthday (month/day only):
Age Range:
18-24
25-35
35-50
51-64
65+
What's the best way to contact you?
Email
U.S. Mail
Phone
Text
Social Media
How would you like to participate:
In Person
Via WebEx
Email
Phone
Other
How often would you be available:
Weekly
Monthly
Every other Month
Quarterly
Other
Have you, or a family member for whom you have provided care, used King's Daughters services?
Yes
No
Rate the quality of the care received
(Optional)
:
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.
Confidentiality Agreement
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)