Board member application

Name *

Email *

Phone *

Address *

Address

Street Address

Street 2 (Apartment, P.O. Box, etc)

City

State/Province

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 *

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 *