Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Gender *

Race/Ethnicity *

Age *

Work Status *

Employement Industry *

Do you have any relatives or friends currently working for Bay Area Community Health? *

If yes, name of relative(s) or friend(s)

Have you, your spouse, or children ever been patients of BACH? *

If yes, name(s) of family who are patients:

If yes, date of most recent medical appointment:

Skills and Experience

Skills and Experience (check all that apply):

If yes to Bilingual, please indicate language

Community Leadership Affliations (check all that apply):

Please indicate board organizations and dates

Fundraising Experience (check all that apply):

Event Planning
Grant Writing
Major Gifts
Individual Giving/Annual Fund

Education

Higher Education (please check all that apply and provide requested information)

Undergraduate College
Post Graduate

Please describe school, degree and major(s)

Employment

Please provide information for your current or most recently held position

Company/Organization

Title

Address

Address Line 1

Address Line 2

City

State

Zip Code

Professional or Personal Reference

Please provide two

Name *

First

Last

Phone *

Email *

Relationship *

Name *

First

Last

Phone *

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.

Signature

I 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.