Visit Category *SelectIndividual VisitCorporate Visit

Name of Visiting Entity *

Date of Visit *

Time of Visit *SelectMorningAfternoonEvening

Name of Focal Point of Contact *

Contact Number of Focal Point *

Patients You Are Intending to Visit *
Children & Young People’s ServicesWomen’s Services

Specify unit(s) *

Purpose of the Visit *
SelectWorkshopEvents or ActivitiesDistributing GiftsOther

Will there be a VIP joining the visit? *
SelectYesNo

Will there be any media coverage? *
SelectYesNo

Are you a: *SelectPatientFamily member of a patient

Religion *

What language(s) do you speak? *
ArabicEnglishOther

Do you or your family member have any chronic health conditions? *SelectYesNo

When was your or your family member’s care experience at this hospital? *Select2026202520242023

Units / Services *SelectChildren & Young People’s ServicesWomen’s ServicesAdult ServicesClinical Support Services

Are you available to serve for at least 1 to 2 years? *SelectYesNo

Would you be available to participate in a meeting for 90 to 120 minutes every other month? *SelectYesNo

What times work best for you? *

Interest Areas *
SelectHelp develop or review informational materialsHelp improve patient safetyHelp improve care decision-makingHelp improve hospital facilitiesHelp educate or train staffImprove hospital admission processInput on bedside shift reportsImprove transitions in careOther

Vaccines received *

Upload Evidence (PDF/JPG)

Willing to take required vaccinations? *SelectYesNo

Please tell us more about yourself *

Why would you like to become a patient and family advisor? *

Please briefly describe any experience you may have as an advisor, volunteer, or public speaker *

Please describe what staff did well or could have done differently *

Have you or a family member experienced healthcare services outside Qatar? *

Have you ever been convicted / cautioned / reprimanded / given a final warning by the police? *SelectYesNo

Is there anything you would like to declare that might conflict with your participation in the PFAC? *

Full Name *

Relationship to Applicant *
SelectParentMotherFatherSpouseSiblingChildOther

Contact Number *

Languages Spoken *
ArabicEnglishOther

Why would you like to volunteer at Sidra Medicine? *

Skills & Experience *SelectPrevious volunteering or healthcare-related experienceSpecial skills or talents

Which days of the week are you available? *

Preferred Volunteering Times *

Hours per week you are able to commit? *

Is there anything we should be aware of to support your participation? *
SelectNoYes

Grade *

School *

Are you a: *SelectPatientSibling of a patient

Religion *

What language(s) do you speak? *
ArabicEnglishOther

When was your or your family member’s care experience at this hospital? *Select2026202520242023

Do you currently have a parent in the PFAC? *SelectYesNo

What are your extracurricular interests / hobbies? *

What are the four reasons why you are interested in becoming a member of the Youth Advisory Council? *

Vaccines received *

Upload Evidence

If not vaccinated, willing to take required vaccinations?SelectYesNo

Commit to attending meetings on: *SelectWeekdaysWeekends

What times work best for you? *
SelectAfternoonEveningOther

Do you have any personal experience that might conflict with your participation? *

Parent Name *

Parent Mobile Number *

Parent Email Address *

Parent Name *

Date *

Consent statement *