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We are seeking the assistance in nominating potential members to participate on the Family Advisory Council. When nominating, please provide detailed answers to the questions on this nomination form. This information will be used to select members to participate on the council.

Please consider the following attributes when making your nomination:
• Share insights and information about their experiences in ways that others can learn from them.
• See beyond their personal experiences.
• Respect the perspectives of others.
• Have a positive outlook on life and a sense of humor.
• Speak comfortably in a group with candor.


Name of person submitting nomination: 
Email Address: 
Best Contact Telephone Number (with Area code):  
Nominee Information 
Parent/Guardians Name: 
Best Contact Telephone Number: 
Address: 
City: 
State: 
Zip: 
Patient’s Name: 
Patient’s Age: 
Child’s diagnosis or condition: 
What strengths or attributes would this parent/guardian bring to the Children’s Family Advisory Council? 
Is there any additional information you would like to provide? 
Authentication * 

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