FAC Membership Application

Thank you for your interest in joining the Family Advisory Council (FAC). Please fill out the form below to apply for membership. Ver en español.

Your Name*:

Last Name*:

Contact information

Email address*:

Your phone number*:

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Other Phone Number:

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Mailing address

Address (line 1)*:

Address (line 2):

City*:

State*:

Postal / Zip Code*:

Tell us about yourself

Please enter the names and ages of your children*:

For example: John Smith (7), Lilly Smith (3), etc.

Can you please briefly describe your experience at Nicklaus Children’s Hospital and what services did you access?*:

Please tell us about your community involvement/volunteer experience*:

Briefly describe your interest for serving on the Family Advisory Council (FAC)*:

Were you referred or recommended by someone? If yes, please provide their name:

By submitting this application, I acknowledge that membership on the Nicklaus Children’s Hospital Patient & Family Advisory Council (FAC) is contingent upon the successful completion of the application process, including*:

A Level I background check (for applicants aged 18 and older).
Submission of required health documentation, including immunization records, as outlined in the FAC Member Guidelines.

I understand that these requirements are necessary to ensure the safety and well-being of all patients, families, and staff. I further agree to comply with all guidelines and policies set forth by Nicklaus Children’s Hospital during my participation in the FAC.

Signature (full name) of the person filling out this form*: