Board member application Board and Committee Member Application Board and Committee Member Application Name * Email * Phone * Address * Address Street Address Street Address Street 2 (Apartment, P.O. Box, etc) Street 2 (Apartment, P.O. Box, etc) City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Please enter a street address where you can be reached. County where you live: * County where you work: * Employer: * Are you, or your dependent children, and/or dependent adult(s), patients of CHC/SEIA and receiving healthcare service from CHC/SEIA? * Have you served on a non-profit board or committe before? * Why are you interested in being board or committee member of CHC/SEIA? * What is your area(s) of experience (citizen/parent/legal/financial/education/social services/etc.)? * Other groups you volunteer with? * Did you receive more than 10% of your pay from a health care organization (mental health, home health providers)? * Yes No Signature * Clear Age * 20 - 34 35 - 44 45 - 64 65+ Gender * Male Female OtherOther Decline to Report Ethnicity * Hispanic or Latino Non-Hispanic or Latino Decline to report Race * American Indian / Alaska Native Asian Black / African American More Than One Race Native Hawaiian Other Pacific Islander White Decline to Report If you are human, leave this field blank. Submit
