Advisory Council Member Application (Live)

Thank you for your interest in Advisory Council Membership with Harris Health System!

Please fill out the application below. Once we receive your application, we will begin to process your paperwork. Please allow two weeks for processing.

The Director at your Health Center will contact you once your application is approved.

New User Details

User ID

User ID (verify)

Password

Password (verify)

HARRIS HEALTH SYSTEM

COUNCIL MEMBER INFORMATION:

Please select Health Center:

Referral Source

* Name prefix

* First Name

* Family/last name

Suffix

Gender

* Date of Birth

* Drivers Licence

* State

* SSN

* Primary Phone Contact

* Email

* Home Address

* City

* State Issued

* Zip Code

Marital Status

Ethnicity

Language

Additional languages

WHY WOULD YOU LIKE TO BECOME AN ADVISORY COUNCIL MEMBER?

Please type below:

EDUCATION AND EMPLOYMENT INFORMATION

Highest Level of Education

School/Major:

Employment Status

Company Name

Current Job Title

Business Experience/Community Memberships

EMERGENCY CONTACT INFORMATION

* Contact name

* Relationship

* Primary Phone Contact

Home Address

City

State

Zip Code

BACKGROUND CHECK AUTHORIZATION:

* I authorize Harris Health System to conduct any and all inquiries necessary to determine my acceptability as a patient advisory council member, including a thorough background check. I understand that this background check may include verification of personal and/or employment references, military information or police record inquiries.

Please Select:

Choose here if you have ever been convicted of or been on defferred adjudication for, or are you now either awaiting trial for or on deferred adjudication for, a felony or misdemeanor.

List and explain convictions if any:

[ clear ]

Please use your mouse or your finger to sign