Family Advisory Council Nomination Form

When nominating a parent or guardian for the Children’s Family Advisory Board or a Family Advisory Council, please provide detailed answers to the questions on this nomination form. This information will be used to select council members. In order to recruit a council that represents families of different backgrounds and medical specialties, we are not able to accept every nominee.

Please consider the following attributes when making your nomination. Family advisors should:

Share insights and information about their experiences in an educational way.
See beyond their personal experiences
Respect the perspectives of others
Have a positive outlook on life and a sense of humor
Feel comfortable speaking in a small group setting
Be willing to share their child’s medical experiences on behalf of Children’s

Self-nominations are welcomed. Nominees can also live outside of the greater Omaha area. Meetings are either fully virtual or offer both virtual and in-person attendance (subject to COVID-19 or other seasonal precautions).

Your Information (person submitting nomination)
Your Name*

First

Last
Your Email*
Your Phone*
Nominee Information
Parent / Guardian's Name*

First

Last
Phone
Address

Street Address

Address Line 2

City

State

ZIP Code
Patient's Name*

First

Last
Patient's Age*
Child's Diagnosis or Condition
For which group is this nomination intended?
- Family Advisory Board
- Children’s Physicians Family Advisory Council
- Cardiac Family Advisory Council
- Endocrinology Family Advisory Council
- Hematology/Oncology Family Advisory Council
What strengths or attributes would this parent/guardian bring to the Children's Family Advisory Council Board or Council?
Is there any additional information you would like to provide?

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Family Advisory Council Nomination Form

Your Information (person submitting nomination)

Nominee Information

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