Fred Hutch Patient and Family Advisor Program Application
Thank you for your interest in volunteering with the Fred Hutch Patient and Family Advisor Program.
Contact info
Name
First
Last
Race/ethnicity
Phone Number
Email
Address
Address
City
State
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
ZIP/Postal Code
I am a (check all that apply):
Patient currently in treatment
Patient with other/rare disease
Family member of patient with other/rare disease
Cancer survivor
Family member of cancer survivor
Family member of a patient who has died
All of the above
I am interested in volunteering as a (check all that apply):
Patient Advisor
Caregiver Advisor
Patient E-Advisor
Caregiver E-Advisor
Meeting availability
Select your availability
to attend meetings and/or events Monday through Friday during the following times (check all that apply). All times are Pacific Standard.
Time frames:
Morning (7 am-11 am)
Afternoon (12 pm-4 pm)
Evening (4 pm-7 pm)
Email or phone only
All of the above
Diagnosis and treatment
You/your loved one’s diagnosis:
Age at diagnosis:
Year treatment completed (if applicable):
If family member, relationship to patient:
If family member, name of patient:
Patient care involved (check all that apply):
Surgery
Radiation therapy
Chemotherapy
Transplant
Integrated/complementary/alternative therapy
Other
Patient care was primarily at:
- Select -
South Lake Union Clinic
Fred Hutch at EvergreenHealth
Fred Hutch at UW Medical Center - Northwest
Issaquah Clinic
Peninsula Clinic
Fred Hutch at Overlake Cancer Center
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