Application Form 
Contact Us
 

Thank you for taking the time to fill out the FCE application. Please review the qualifactions below and then complete the application. In addtion, please print, sign and mail the Informed Consent.

Qualifications:

• Have a chronic medical condition that significantly impacts your life on a daily basis;
• Can commit to mentor for at least two years;
• Have a willingness to share stories about your illness and life;
• Require regular physician visits for treatment of illness; and
• Live within 30 miles of Ann Arbor


Before submitting this application, please review it for accuracy. If you have any questions, please contact fce@umich.edu or by phone at (866) 337-0017.

Title
 
Last Name
 
First Name
 
Street Address
 
City
 
State
 
Zip
 
Age
 
Date of Birth (mm-dd-yyyy)
 
Home Phone Area Code
Home Phone number    
Work Phone Area Code
Work Phone number    
Mobile Phone Area Code
Mobile Phone Number  
Email
 
   
Family Information
 
Number of people in your immediate family living at home
 
 
Name Age Relationship to you
Please respond to the following questions:
 
What is the nature of your chronic medical condition?
Why are you interested in particapating in the Family Centered Experience?
How did you hear about the Family Centered Experience?
I confirm that the above information is true and correct to the best of my knowledge. Please click below if you agree with this statement.
I agree.