Bay Area Community Health Board of Directors applicationPlease enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone *Gender *Choose OneMaleFemaleRace/Ethnicity *Choose OneAfrican AmericanAsianLatinxNative AmericanPacific IslanderWhiteOtherAge *Work Status *Choose OneFull-time employedPart-time employedRetired/homemakerCommunity leader/volunteerOtherEmployement Industry *Choose OneFinancial InstitutionLawEducationPublic Relations/MarketingGovernmentHealth ServicesNonprofitIT/SoftwareOtherDo you have any relatives or friends currently working for Bay Area Community Health? *Choose OneYesNoIf yes, name of relative(s) or friend(s)Have you, your spouse, or children ever been patients of BACH? *Choose OneYesNoIf yes, name(s) of family who are patients:If yes, date of most recent medical appointment:Skills and ExperienceSkills and Experience (check all that apply):Long-range Planning/Capital ExpansionPersonnel/HRManagement/Organizational Development Project ManagementVolunteering/Community involvementFinancial ManagementInformation TechnologyLegal/LawMarketing/PRBilingualIf yes to Bilingual, please indicate languageCommunity Leadership Affliations (check all that apply):Community/Neighborhood LeaderFaith CommunityCurrent or Former Board Participation Link to Funders/Individual DonorsService ClubsPlease indicate board organizations and datesFundraising Experience (check all that apply):Event PlanningGrant Writing Major GiftsIndividual Giving/Annual FundEducationHigher Education (please check all that apply and provide requested information)Undergraduate CollegePost GraduatePlease describe school, degree and major(s)EmploymentPlease provide information for your current or most recently held positionCompany/Organization TitleAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProfessional or Personal ReferencePlease provide twoName *FirstLastPhone *Email *Relationship *Name *FirstLastPhone *Email *Relationship *Why Bay Area Community Health?In a few sentences, please tell us why you would like to join the Bay Area Community Health Board of Directors and how you think you can help the Board and the organization. *Date of Application *Checkboxes *By checking this box, I am indicating that I understand that I am authorizing Bay Area Community Health (BACH) representatives to contact my former employers, references, and educational institutions named in this application. I understand that BACH is not obligated to provide a position on the Board of Directors, nor am I obligated to accept a Board position if offered. I understand that any information obtained by BACH in the course of these contacts will be treated in the strictest confidence.By checking this box, I confirm that I am 18 years of age or older.SignatureClear SignatureI certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that should this application contain any false or misleading information, my application may be rejected.EmailSubmit