Board of Directors Application Form

Board of Directors Application Form

Thank you for your interest in joining our Board of Directors! For questions or concerns regarding the application, please email Teena Kindt, Chief Executive Officer of the Alzheimer Society of Niagara Region, at tkindt@alzheimerniagara.ca
Which organization's Board of Directors are you applying for?*

Alzheimer Society of Niagara RegionAlzheimer Society Niagara Foundation
Personal Information
Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone #1*
Please enter a valid phone number.Format: (000) 000-0000.
Phone #2
Please enter a valid phone number.Format: (000) 000-0000.
Fax #
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Business Information
Occupation*
Place of Business
Title
Years With Organization
Business Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Fax #
Please enter a valid phone number.Format: (000) 000-0000.
Pager #
Please enter a valid phone number.Format: (000) 000-0000.
Business Email
example@example.com
I would prefer to receive emails at my:*

Personal emailBusiness email
Previous Experience
Recreational Interests/Qualifications/Skills:*
Affiliations/Community Involvement (other boards, professional groups/associations, service clubs, political organizations):*
Previous Fundraising Experience
Past Campaigns:
Events/Activities:
Commentary
What do you think you could contribute to the organization as a member of the Board?*
Would you be willing to represent the organization at various events/activities held by the Foundation, Society or other organizations?*
What special interests would you like to pursue?*
Would you be willing to join other fundraising committees:*

Walk For MemoriesGolf TournamentNone
Are you comfortable with sharing the Foundation's vision and asking for a financial investment from others?*
How did you hear about us?*
Please elaborate on any experience/awareness you have regarding persons living with a dementia.*
References
Reference #1
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone #1*
Please enter a valid phone number.Format: (000) 000-0000.
Phone #2
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
Reference #2
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone #1*
Please enter a valid phone number.Format: (000) 000-0000.
Phone #2
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
I authorize the Alzheimer Society of Niagara Region to collect personal information appropriate to the position applied for concerning my academic background, employment history, and verify the character references I have supplied. I understand that the information obtained will be confidential.
I authorize the Alzheimer Society Niagara Foundation to collect personal information appropriate to the position applied for concerning my academic background, employment history, and verify the character references I have supplied. I understand that the information obtained will be confidential.
Signature
Should be Empty:

Board of Directors Application Form

Personal Information

Business Information

Previous Experience

Previous Fundraising Experience

Commentary

References

Reference #1

Reference #2