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Yuma Regional Medical Center
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Patient and Family Partner Application

Thank you for your interest in becoming a Patient and Family Partner at Yuma Regional Medical Center.  This application is an opportunity for us to get to know you and find out a little about your experiences here at YRMC.

Today's Date  Calendar (mm/dd/yyyy)
Street Address 
Mailing Address 
Home Phone 
Work Phone 
E-mail Address 
What is the best way to contact you (home, work, or e-mail)? 
Please specify times when you are able to attend meetings 

If Other, please specify:

Have you or your family ever used any of the following services at Yuma Regional Medical Center 

If Other, please specify:

Other than English, what other language do you speak?  
Why would you like to serve as a Patient and Family Partner? 
What would you like us to know regarding your past experience(s) receiving care at YRMC?  
Have you done public speaking or teaching? If so, please describe?  
Is there any other information you would like to share with us in considering your application?  
Do you know any other individuals or families who have experienced care at Yuma Regional Medical Center who might be interested in serving as partners? Please call them for us or list the name(s) and phone number(s) below:  
Are there any past or current volunteer/community groups that you are or have been involved with? 
Authentication * 

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© 2016   Yuma Regional Medical Center  |  2400 S. Avenue A  |  Yuma, AZ 85364  |  928-344-2000