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.

Advisory Council Member Application

HARRIS HEALTH SYSTEM
COUNCIL MEMBER LOCATION:
Name prefix
First Name
MI
Last Name
Suffix
Home Address
City
State
Zip Code
Home Phone
Cell Phone
Work phone
Email
Date of Birth
Gender
Marital Status
Social Security #
Drivers License or ID#
State Issued
Ethnicity
Language

EMERGENCY CONTACT INFORMATION
Contact name
Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
EDUCATION AND EMPLOYMENT INFORMATION
Highest Level of Education
School/Major:
Employment Status
Company Name
Current Job Title
Business Experience/Community Memberships
WHY WOULD YOU LIKE TO BECOME AN ADVISORY COUNCIL MEMBER?
Why?
Member source

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.
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: