Children's of Mississippi

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COM PFAC Application Form

Children's of Mississippi Patient and Family Advisory Council (COM PFAC)
Membership Application

Name*
Phone
Address*
City/State/Zip code*

  -

Email*
Communication preference*

Please briefly describe your child's medical story
List areas of Children's of Mississippi service(s) you've experienced

If outpatient clinic(s), please list:
I am a Children's of Mississippi:*

Please specify:
Are you able to make a commitment to attend monthly team meetings and additional time (outside of COM PFAC meetings) on a periodic basis for projects, focus groups and committee work?

Please briefly share why you would like to be a part of the COM PFAC at Children's of Mississippi*

Hospital Recommendation

We would like to ask a healthcare professional to support your application. Please provide us the name of a doctor, nurse, child-life specialist, social worker, or staff member who would recommend you.
Name
Phone
or Email



Please note: Council members are considered volunteers of the hospital and are subject to a background check by the hospital?s Volunteer Services Department.