Register for PFAC | Waterbury Hospital

The Council requires a 4-month commitment. Are you able to commit? Yes No Maybe

What services have you used? Emergency Room Blood Draw Stations I've been admitted to a floor/unit Outpatient Doctor's Office

Your Full Name

Your Date of Birth

Why are you interested in joining the Council?

What if your gender identity

What are your preferred pronouns?

What is your sexual orientation?

What is your ethnic or cultural background?

What languages can you speak?

Do you identify with a religion? (If yes, please indicate the religion you identify most closely to. If not simply enter NO.)

Are you hearing or visually impaired? Hearing Visual Both Neither

Do you require an interpreter? If so, enter What language interpreter/translator

Home Address

Your City

Your Zip Code

Your Cell Phone Number

Your Email Address

PFAC Application Form