PeopleCare Advisory Program

Contact Information

* First name

* Last name

* Phone Number

* Email Address

* Address Line 1

Address Line 2

* City

State

* Zip

Prefered form of contact

Phone

Email

Recent Healthcare Experiences

Association with Wellstar - Check all that apply

I am a patient of Wellstar Health System

I am a family member of a patient of Wellstar Health System

I am involved in the care of someone who is a patient of Wellstar Health System

I am a Wellstar team member and a patient family or caregiver

* Please share with us your interest in being a patient and family advisor. This could be a recent or previous experience with healthcare. Please include your thoughts of what went well and if applicable what could have been done differently.

* Skills & Interest: If you wish to provide more information, please use the space below to describe any special training, interests, hobbies or experiences you feel could be valuable to your work as a Patient/Family Advisor with us.

Preferred pronouns

Demographic Information

Ethnicity

Languages

Gender

Age

Experience Information

At which facility or facilities have you or a family member received services in the past 2 years, and which service lines have you utilized most frequently?

Wellstar Cobb Hospital

Wellstar Douglas Hospital

Wellstar Kennestone Hospital

Wellstar North Fulton Hospital

Wellstar Paulding Hospital

Wellstar Spalding Hospital

Wellstar Sylvan Grove Hospital

Wellstar West Georgia Hospital

Wellstar Windy Hill Hospital

Wellstar Acworth Health Park

Wellstar Avalon Health Park

Wellstar Cherokee Health Park

Wellstar East Cobb Health Park

Wellstar Vinings Health Park

Wellstar MCG Health

Wellstar Urgent Care Centers

Wellstar Medical Group Offices (Primary care offices etc.)

Which service lines have you utilized most frequently?

Cardiology

Emergency Services or Urgent Care

Infusion

Lab

Oncology

Radiology

Respiratory

Rehabilitation (Physical Therapy)

Other

* Please indicate which service line was not covered in the options above.

Which Advisory Council(s) are you interested in learning more about?

Wellstar Cobb Hospital

Wellstar Douglas Hospital

Wellstar Kennestone Hospital

Wellstar North Fulton Hospital

Wellstar Paulding Hospital

Wellstar Spalding Hospital

Wellstar Sylvan Grove Hospital

Wellstar West Georgia Hospital

Wellstar Windy Hill Hospital

Wellstar MCG Health

MyChart

Oncology

Spanish Speakers

System/Shared Services

I'm interested in a topic not listed here

* Please state your other interest here.

I Agree

I understand and agree that submitting this application form does not automatically register me as a Wellstar volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering. I understand that my services are voluntarily donated to the hospital and I do not expect to receive compensation of any nature, to include financial compensation, academic credit and/or future employment. Applicant must sign a release for a Criminal Background Screening by state and federal agencies. Persons who have been convicted of any felony offense or misdemeanor offenses involving drugs, child abuse, assault, and/or any violent behavior are not eligible to volunteer. Reminder: If you were born after 1957, an immunization record must be submitted. Required vaccines include 2 MMR, 2 Varicella, and 1 Tdap. During flu season (Sept-March) a current flu vaccine is also required. By submitting this form, I attest that the information I have provided on the form is true and accurate.  Eligibility I understand and agree that submitting this interest form does not automatically register me as a Wellstar PeopleCare Advisor, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering. I understand that my services are voluntarily donated to Wellstar Health System, and I do not expect to receive compensation of any nature, to include financial compensation, academic credit and/or future employment. Applicates must sign a release for a Criminal Background Screening by state and federal agencies. Persons who have been convicted of any felony offense or misdemeanor offenses involving drugs, child abuse, assault and/or any violent behavior are not eligible to volunteer.  Meeting Participation/Frequency I understand this is an active volunteer role. If accepted, I agree to actively participate in the PeopleCare Advisor Council to support Wellstar's PeopleCare mission by sharing insights, identifying opportunities for improvement, and collaborating to enhance the patient and family experience. I will engage with compassion, listen with respect, honor every voice, and partner with others to promote meaningful connections and continuous improvement in care delivery. I am willing to talk about my experiences constructively I can easily work with people from different backgrounds who may have differing viewpoints I must be willing to keep information I hear private and confidential These councils meet eight to ten times per year depending on the hospital location (in-person and virtually). If accepted, I will do my best to attend all meetings. In addition, I agree to provide timely responses to electronic inquiries for feedback between meetings and to participate in additional workgroup planning sessions as needed.  Reminder: If you were born after 1957, an immunization record might be required. Required vaccines include 2MMR, 2 Varicella, and 1 Tdap. During flu season (September-March) a current flu vaccine might be required. This is location specific and depends on your involvement with quality/safety journey mapping projects (i.e.-simulations, observations, interviews, storytelling at staff meetings). By submitting this form, I attest that the information I have provided on this form is true and accurate.