Board of Directors Application Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Applicant Details Gender * Male Female Non-Binary Race/Ethnicity * African American Asian Latinx Native American Pacific Islander Caucasian Other Age * Work Status * Full-time employed Part-time employed Retired/homemaker Community leader/volunteer Other Employment Industry * Financial Institution Law Education Public Relations/Marketing Government Health Services Nonprofit IT/Software Other Do you have any relatives or friends currently working for Bay Area Community Health? * Yes No If yes, name of relative(s) or friend(s) Have you, your spouse, or children ever been patients of BACH? * Yes No 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): Long-range planning/capital expansion Management/organizational development Volunteering/community involvement Information Technology Marketing/PR Personnel/HR Project Management Financial Management Legal/Law Bilingual If yes to bilingual, please indicate language: Community Leadership Affiliations (check all that apply): Community/Neighborhood leader Current or former Board participation Service Clubs Faith Community Link to Funders/Individual Donors 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 on your current or most recently held position: Include Company Name, your Title and Company Address Professional or Personal Reference Please provide two Reference #1 Name * First Name Last Name Reference #1 Phone * (###) ### #### Reference #1 Email * Your relationship to Reference #1 * Date of Application * MM DD YYYY Authorization Checkbox * By checking this box, I am indicating that I understand that I am authorizing Bay Area Community Health (BACH) representatives to contaact 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 underfstand 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. Your Name as 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. First Name Last Name Thank you!
