Prospective Board Member Application Form
Confidential - Please provide the following information for consideration by the Governance Committee.
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Name:
First Name
Last Name
Physical Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
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Current Job Title:
Professional Skills:
Type of Work Experience:
Special Interests:
Education:
Please describe your leadership/or volunteer experience, listing any positions held or organizations where you have volunteered:
Area(s) of expertise and/or contributions you feel you can make at One Community Health as a Board Member:
Other volunteer commitments you have made:
Do you or does any member of your immediate family (domestic partner, spouse, children, parents, in-laws) have a “relationship” (work, consulting, income, contractual agreement, affiliation, board membership or other interest) with any of the following?
Hospital/medical center/nursing home/home health/pharmacy/other health care organization or clinic
Supplier of goods to health center or medical group
Health insurance company or HMO, PPO
Law firm
Board member of another organization
Other healthcare related organization
Please specify the industry and list the nature of the relationship:
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Are you a patient of One Community Health?
Yes
No
Have you had a visit within the past 24 months?
Yes
No
Do you feel you represent an OCH patient group or special population we serve? (migrant seasonal farmworker, Native American, other)
What motivates you to volunteer for a health care board of directors?
Which parts of One Community Health’s mission or work inspires you? (e.g., our value: we recognize the importance of caring for people who face barriers in accessing services because they have difficulty paying for services or because they have language or cultural differences and disparities in their health status.)
How much time do you have available for One Community Health Board service?
What expectations do you have from the management of One Community Health on whose board you would serve?
Do you have personal aspirations that could be enhanced by service on our board? (As an advocate; marketing; speaking on behalf of center, etc.)
Do you anticipate any professional or personal constraints on your time or service as a volunteer board member?
Is social interaction with other board members important to you?
How do you feel the performance of a Board should be evaluated?
Do you see yourself as an ambassador and advocate? Would you consider actively advocating on behalf of OCH’s strategic goals to others locally or at the state level?
Is there anything else you would like to tell us about yourself?
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