Name

Pronouns

Date

Address

City

County County Marion Polk Other

Other

State

Phone Number

Email

Current Employer (Optional)

Job Title (Optional)

Tribal Affiliation (optional) Tribal Affiliation (optional) Confederated Tribes of Grand Ronde Confederated Tribes of Siletz Confederated Tribes of Warm Springs Other

Other

Oregon Health Plan (OHP) Status: Check all that apply) Oregon Health Plan (OHP) Status: Check all that apply) I have OHP. My Card is with... My Child or dependent has OHP. Their card is with... I have both Medicaid (OHP) and Medicare I have been an OHP Member in the past I have never been an OHP Member Other

New Field

I have OHP. My Card is with... I have OHP. My Card is with... PacificSource Open Card Other I don't know

Other

My Child or dependent has OHP. Their card is with... My Child or dependent has OHP. Their card is with... Pacific Source Open Card Other I don't know

Other

1. Please tell us about yourself, including your background, your culture, and/or the point of view you would bring to the Community Advisory Council

2. Please tell us about any experiences you have had with healthcare and/or what interests you about healthcare.

3. Why do you want to be a part of the Community Advisory Council (CAC)?

How did you hear about this opportunity How did you hear about this opportunity Flyer Social Media Willamette Health Council Website PacificSource Website A friend My doctor or provider Other

Other

Would you be interested in learning more about opportunities to serve on the WIllamette Health Council Board of Directors, Clinical Advisory Panel, or Community Impact Committee? Would you be interested in learning more about opportunities to serve on the WIllamette Health Council Board of Directors, Clinical Advisory Panel, or Community Impact Committee? Yes No Not Sure

Please list two people who could tell us about what you could contribute as a member of the Community Advisory Council. (Provide: Name, Relationship, Phone, and Email for both references)