Patient Advisors Network Membership Request Please tell us a bit about yourself, your healthcare interests, and your experience of being an advisor in healthcare. Once we receive the form, we will be in contact with membership details. Regards, the PAN teamFirst Name *Last Name *Email *Phone *City/Town *Province *Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweHave you ever worked in healthcare or are you currently employed in healthcare? *YesNoCurrent status *I am interested in becoming a patient and family advisorI am currently a patient and family advisorI have been referred to PAN byDo you have experience as... (Check all that apply.)I am a *Patient or Resident or ClientFamily CaregiverFriend CaregiverI have experience taking care of the following people with health issues.A childA parentA spouse or partnerAn adult relation (sibling or other relative)Areas of Experience and InterestACUTE CAREAs a PFA (Patient and Family Advisor) in my local hospitalOn an advisory or community council at my local hospitalPRIMARY CAREAs a PFA (Patient and Family Advisor) in my primary health provider's practiceAs a PFA (Patient and Family Advisor) in my specialist health provider's practiceOn a council for a primary care group or teamCOMMUNITY CAREAs a PFA (Patient and Family Advisor) in my community and home care provider's organizationOn an advisory or community council at a community or home care provider organizationLONG TERM CAREOn a residents' council in my long term care facilityOn a family council in my loved one's long term care facilityAs an advisor on an association of councils for long term careMENTAL HEALTH CAREAs a client or family advisor (in my provider's organization)On a council for a mental health organization or care teamREHABILITATION FACILITYOn a resident's council in my facilityOn a family council in my loved one's facilityAs an advisor on an association of councils for a rehab facilityFOR THE HEALTH SYSTEM On an advisory group or council forMy local health authorityMy provincial quality councilMy provincial ministryOtherRESEARCH (NOT as subjects of research but as partners)As a partner on a research team or teamsReviewing research applications for a funding organizationSetting research priorities for a funding organizationEDUCATIONFor healthcare professionalsFor patient and family advisorsMentoring others and peer supportMentoring other advisorsSECTOR INTERESTS My sector interests are inAcute CarePrimary CareSpecialist CareCommunity careLong Term CareMental HealthRehabilitationEducationSystem - health authorities, ministries, quality councilsResearch in a role other than as subjectHEALTHCARE INTERESTS My healthcare interests areDisease specificHealth SystemEvidence - based medicineMedications - Polypharmacy,Shared decision-makingCare coordination and transitionsAdverse events and complaintseHealth and digital health informationOtherPARTNERING ISSUES I am interested in the following partnering issuesTokenismCompensation (not just expenses)Levels of engagementOtherPlease describe other partnering issues you are interested in.KEY WORK and VOLUNTEER BACKGROUND What are the key things you have done that help you in your partnering.Thank you for sharing your experience and interests. You will hear from us soon. Regards, The PAN TeamSUBMITPlease do not fill in this field.