Patient Expert Programme – Apply Here! – Académie des Patients Experts / The Patient Expert Academy

Patient Expert Programme - Application Form

1. Personal information

First Name

Last Name

Phone number

Pronouns

Other pronouns

Date of birth

Address

Address Line 1

Address Line 2

City

Zip Code

Country

Preferred contact method

Phone

Other

Other contact method

Other languages spoken (optional)

2. Eligibility

Are you over 18 years old?

Yes

Do you live with a chronic illness and/or disability? (This programme is specifically for people with lived experience.)

Yes

Prefer not to say

(Optional) If you wish, describe your chronic illness or disability. You may remain as general or specific as you like.

Where do you receive most of your healthcare? (e.g. CHL, HRS, CHEM, clinicians in Luxembourg)

3. Your Lived Experience

How has your experience shaped your life? (Max. 250 words)

If yes, briefly describe your involvement

4. Motivation & Goals

Why do you want to join the Patient Expert Programme? (Max. 250 words)

What skills or knowledge would you like to develop?

How would you like to use your Patient Expert competencies in the future?

5. Practical Information

Are you able to attend the programme sessions (held in Steinsel, Luxembourg)?

Yes

Mostly, with occasional restrictions

No / Unsure

If “Mostly” or “No / Unsure,” please explain:

Do you have any accessibility or support needs for your participation?

6. Diversity & Inclusion (Optional)

Do you identify with any communities under-represented in healthcare?

Anything else you would like us to know about your context?

7. About Your Application

How did you hear about the programme otherwise?

8. GDPR Consent

I confirm the information provided is accurate.

I understand my data will be used only for this programme and processed under GDPR.

I agree to be contacted regarding my application.

I consent to anonymised quotes being used for reporting. (Optional)

Data controller: Académie des Patients Experts / The Patient Expert Academy

Contact: gdpr@patex.lu