Submission Form - Patient-partners

Notes :

1. The Hospital reserves the right to accept or refuse any submissions, the selection will be based upon its needs. You will be contacted within 30 days following this submission.

2. The personal information contained in this form is gathered under the terms of the Public Hospitals Act and Freedom of Information and Protection of Privacy Act and will be used solely for the purposes of selection for the position of Patient Partner Advisor at Hôpital Montfort. This information will not be shared without the authorization of the candidate/parent or guardian.

First Name

Last Name

Address

City

Postal Code

Phone number

My motivation

In the last two years, have you, a family member or a friend, used the services of Hôpital Montfort?

Yes

Why would you like to become a Patient Partner for Hôpital Montfort?

What changes would you like to see at Hôpital Montfort?

My availability

Most meetings at the Hospital are held Monday to Friday between 7 a.m. and 7 p.m. Please specify below the times you would be available to attend meetings.

Monday

(M) De :

À :

Tuesday

(Tu) De :

À :

Wednesday

(W) De :

À :

Thursday

(Th) De :

À :

Friday

(F) De :

À :

My interests

I am especially interested in participating in the following services: