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Thank you for your interest in the Patient and Family Partnership at University of Missouri Health Care. We are seeking patients, family members and friends who want to make an impact on health care.

Please complete this short questionnaire. Applicants will be contacted to schedule an interview and will be asked to supply a list of references. Applicants selected must be available to attend new member orientation.

If you have any questions or need this application in another form or language, please call
(573) 882-2235 or email harriskd@health.missouri.edu.

First name 
Middle initial 
Last name 
Street Address 1 
Apartment/Unit # 
Email Address 
Best time to receive calls: 
Age range: 
Primary language spoken: 
Other languages you speak: 
Would transportation or child care be an issue? 
If yes, please explain: 
In what area(s) are you interested in representing?
Check all that apply 

Best time available for meetings: 
The following are ways you can be involved as a patient/family partner.
We do not expect you to have extensive experience in health care but we are interested in learning more about your experiences.  
Advisory Council Member:
Membership on the Council to offer input on planning, programs and policies;
identify patient and family concerns;
and partner with staff to advise and promote patient family centered care. 
Patient/Family Partner:
Membership on a specific sub-committee that is charged with a particular responsibility such as conferences,
reviewing brochure/websites, new program development, new facilities,
collaborating with staff. 
Task Force member:
Occasional family/patient group meetings to give feedback or suggest solutions on a specific topic
(Time commitment: as needed basis) 
Please check boxes below:
Check all that you are interested in 

What facility have you or your family member(s) used?
Check all that apply 

Which facility have you or your family member(s) received service in the past year?
Check all that apply 

Which facility have you or your family member(s) received service more than one year ago?
Check all that apply 

We believe our patient and family partners should reflect the diversity of patients, families and friends who use our hospitals and clinics. In light of this, please share anything about yourself that you think would add to the diversity of our committee. 
What do you feel you can contribute by becoming a patient/family partner? 
I acknowledge that I have provided accurate information to the best of my ability.
Please initial: 

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