Patient and Family Advisory Board Application

Complete this application if you are interested in joining our Patient and Family Advisory Board. The applications will be reviewed and if you are one of the final candidates, you will be contacted for an interview.

Please include the following information with the application:
Current resume, or biographical statement, outlining personal, professional or volunteer experience.

An interest statement including but not limited to:
Why you are interested in the advisory board
What patient advocacy means to you
Why you believe you would be an advocate for patient/family care
What qualities or skills you can contribute.

Your Information

About You

First name

Last name

Contact Methods

Your Patient's Phone number (###-###-####)

Your Patient's Email Address *

Residential Address

Street address

City

State

Zip code

Your Involvement

Are you involved in any other activities at Roswell Park Comprehensive Cancer Center? *

Attach resume here:

Attach statement of interest here:

Your Information

About You

Contact Methods

Residential Address

Your Association to Roswell Park

Your Involvement