Neonatal Network Family Advisory Council Application First Name Last Name Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Daytime Phone Evening Phone Email Occupation / Employment Employment Status Full Time Part Time Educational Background Name of Spouse / Partner (if applicable) Names and Ages of Children Nationwide Children’s Hospital services used by family (please specify NICU locations and discharge dates if applicable) Community Involvement / Volunteer Experience Describe your interest for serving on the Family Advisory Council What interests do you have? (check all that apply) Assembling Crafts Planning Crafts Volunteering at Marquee Events Being a Council Officer (Parent Co-chair, Secretary) Committee Chair Committee Member Would you have an interest in leading a Parent Pizza Night? Parent pizza nights are support group meetings for parents of babies in the NICU. Yes No If yes, how often could you host? Once a month 2 times a month 3 times a month Weekly Which location(s) would you be willing to serve? Doctor's Hospital Dublin Methodist Hospital Grant Medical Center St. Ann's Generally, what is your availability to volunteer on-site?Monday Tuesday Wednesday Thursday Friday Saturday Sunday Generally, what is your availability to volunteer remotely?Monday Tuesday Wednesday Thursday Friday Saturday Sunday Additional Comments
