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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 Submit
