LeadUS Mentoring Program 2015-16

Board of Directors Applicant Form

EMPOWER-ED
Personal Information
Name

Last NameFirst Name
Date

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Birth Date

MonthDayYear
Demographic Information
Gender Identity

MaleFemaleOther
Ethnicity
Nationality
Business/Work Information
Title/Profession
Company Organization
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Format: (000) 000-0000.
Please list your current and past Board experiences, if any.
What are your current associations and/or club affiliations? (include titles if possible).
Please list your skills and expertise.
What is your educational background?
Please describe in details some of your greatest strengths and weaknesses.
What do you feel is essential to ensure that the Board and staff are successful in attaining the goals for this organization?
Please detail your interest in joining this Board.
As you may know, working with youth and underserved communities involves numerous creative and innovative ideas. Please inform us if you have any specific project ideas you would like to propose in the near future.
Have you ever been engaged in any specific fundraising efforts? If so with whom, how, and what was the amount raised?
Empower-ED Board will initially have 4 standing committees: (1) Strategic & Planning, (2) Educational Development & Programming, (3) Finance & Human Resources, and 4) Research & Development. Please check all that you would be interesting in joining.

Strategic & PlanningEducational Development & ProgrammingFinance & Human ResourcesResearch & Development
This board is an exciting and engaging working board. Board members are required to participate in a minimum of 11 monthly virtual board meetings per year, one annual face-to-face meeting per year, and a minimum of 11 standing monthly committee meetings, which occur outside of regular board meetings (this can happen by phone or virtually). Board members are expected to be timely and present at every meeting with a maximum of two absences per year from board meetings. Between work within and outside of meetings, hours of commitment can vary up to 10-15 hours per month. Board members are also encouraged to participate in fundraising and development activities, which include an annual gift to Empower-ED that is personally significant and meaningful. Board members are expected to commit to the role for a minimum of 2 years. Will you be able to make this commitment to Empower-ED?

YesNo
If you are not able to commit 10-15 hours per month, please elaborate on the amount of hours that you are capable of serving.
Resume

Cancelof
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.

We understand that your time is extremely valuable and we appreciate your interest in serving our Board.

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

MonthDayYear
Date
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Board of Directors Applicant Form

Personal Information

Demographic Information

Business/Work Information