JHHCC Teen and Children's Council Application

Thank you for your interest in joining a Johns Hopkins Hospital Patient and Family Advisory Council! Council members are essential partners in the Hospital's mission to provide excellent patient- and family-centered care.

Please fill out this secure form. If you have any questions, feel free to contact us at patientfamilycouncil@jhmi.edu.

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Patient and Family Advisory Council (PFAC) Volunteer Application: Teen and Children's Council

Before completing this form you will need an adult other than your parent or guardian to provide a few sentences about why you are a good candidate for the Youth Advisory Council. You will be asked for that information in the "Adult Recommendation" Section.

Note: *Fields highlighted in yellow are required*

* Yes, I'm interested in becoming an active member of the Teen and Children's Council (TACC) at the Johns Hopkins Children's Center

Site for TACC

The following statements are requirements to join the Council. Please review them and check off the statements that are true.

Personal Information

* First Name

* Last Name

* Home Address

* City

State

* Zip Code

* Date of Birth

* E-mail Address

* Primary Phone

Secondary Phone

Primary Language

Additional Language(s): select all that apply

Are you over 18 years old?

Allergies/Food Allergies

Activities and Hobbies

* Are you currently being treated? Have you been treated at the Johns Hopkins Children's Center?

* Please write a few sentences explaining why you want to be part of the council.

Parent/Guardian Information

(Please ask your parent or guardian to fill out the following fields.)

* Parent/Guardian First and Last Name

* Phone Number

* Please describe why you feel the applicant would be a good candidate for the Youth Advisory Council.

* Parent/Guardian Virtual Signature

* Date

Adult Recommendation

(Please ask an adult other than your parent or guardian to fill out the following fields.)

* Adult First and Last Name

* Phone Number

* Please describe why you feel the applicant would be a good candidate for the Youth Advisory Council.

* Adult Virtual Signature

* Date

Confidentiality Agreement

Click here to review the Confidentiality Statement

* By checking this box, I agree that I have downloaded, read, and understand the JHM Confidentiality Statement.

Final Steps

CONFIDENTIALITY: All information contained in this form is considered confidential and is intended for use by the Johns Hopkins Childrens Center Teen and Childrens Advisory Council Membership Committee. The Committee will maintain appropriate and confidential handling of personal information as stated in HIPAA guidelines and is presented in volunteer training. Qualified applicants will be selected to participate in a face-to-face interview. If selected, all Teen and Childrens Advisory council applicants must complete volunteer service requirements as assigned by the Volunteer Services department. These volunteer requirements include, but are not limited to the completion of the following: volunteer application, reference and criminal background check, volunteer orientation, HIPAA training and badge identification.

All patients served by the Johns Hopkins Children's Center are welcome to apply for membership as a Teen and Childrens Advisor.

* Applicant Virtual Signature

* Date

Parent/Guardian Virtual Signature

Applicant Virtual Signature

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(Please sign in the box using your mouse or keypad)

* Date

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