LeadUS Mentoring Program 2015-16

Board of Directors Canidate Applicant Form

Thank you for your interest in serving as a member of the Board of Directors of the Central Coast Childbirth Network. Serving on the board is a rewarding experience and an opportunity for personal and professional growth. Completing this form will help you understand the skills and time/resource commitments of this leadership position. You may find it helpful to read through the entire application and Board Member Responsibilities before you begin filling it out. This application will be kept confidential and on file with the Secretary. Applications are used by the Board of Directors to identify and evaluate potential board candidates. All new directors are elected by a majority vote of current board members. Please review Directors & Officers Roles and Responsibilities and the CCCN Vision, Values and Mission. If you have any questions please contact Zabrina at zabrina@centralcoastcn.org or Susannah at Susannah@centralcoastcn.org.
CCCN Mission, Vision, Values & Board Expectations
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Applicant Name *

Last Name First Name
Applicant Address *

Street Address

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Applicant Phone Number *
Applicant Email *
Applicant Birth Date *

Month Day Year
My current principal employment is as follows (Name of Employer & Address/Position or Duties): *
Please share with us why you are interested in joining our organziation: *
Have you served on other nonprofit organization boards? If so, please list them and any offices you held: *
What personal or professional skills and strengths would you bring to the CCCN? Include any experiences, expertise, connections and resources. *
What current associations, club affiliations, and/or volunteer commitments do you currently have? *
Please check any of the following ways you are willing to support CCCN: *

Vice President Committees: Governance, Internal, External, and Diversity, Equity, and Inclusion CCCN to Professionals Program CCCN Professionals to Community Program Program Director Fundraising
CCCN Organizational Structure 2021
After Reviewing the CCCN “Conflict of Interest Policy” Please Explain if you are aware of any situation that might be perceived by others as a “Conflict of Interest” if you are appointed: *
After your application has been reviewed you may be asked to interview in order for us to better get to
know you. Please have a list of references available upon request. Thank you for your interest.
I certify, by my signature, that the information contained within this application and all supporting
documents (i.e., resume, recommendation letters, etc.) is true, accurate, and complete to the best of my knowledge. An electronic signature is accepted.

Signature________________________ ___________ __Date_____________

Central Coast Childbirth Network, INC ensure the right of all association members to appropriate and effective services without discrimination on the basis of the organization’s volunteer or staff make-up in respect to gender, sexual orientation, national origin, race, religion, age, political affiliation or disability, in accordance with all applicable legal and regulatory requirements.
Please attach resume.

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Board of Directors Canidate Applicant Form