Thank you for your interest in improving the quality, safety, and experience of care at Children's Mercy. Please answer the following questions to complete the Patient Family Advisory Council (PFAC) application. Information shared in this application is on a secure server and will remain confidential

If you are filling out this application on a mobile device, please make sure your screen orientation is unlocked and turn your phone to the side (landscape mode) to complete the application.

Please create a New User account to apply by completing the User ID Field and Password Field below.

All items with ( * ) indicate a required field.

Personal Information 

Communication Methods

Primary Home Address
Education
Employer
Volunteer Affiliation(s)
Emergency Contact Information 

Your Experience at Children's Mercy

The information you enter into this form will be held in the strictest of confidence and will not be used or disseminated for any purpose other than as a tool to determine membership eligibility.

Please provide the name(s) and birthdate(s) of your children who are cared for at Children's Mercy. If you are a patient applying for a PFAC, please enter your information here.

Consent and Acknowledgement Section

For adult volunteers (18+), please review, acknowledge each item below and sign this consent page. For minor volunteers and adult volunteers with a guardian; your parent/legal guardian will be sent a seperate email to review, acknowledge and sign consent in order to participate in the volunteer program

Please add your signature to complete the application and sign off on your agreements to the statements above.