LeadUS Mentoring Program 2015-16

VHF Board of Directors Interest Form

For Questions Contact, Kelly Waters at 804-740-8643 or info@vahemophilia.org
Date*

MonthDayYear
Date
Personal Information
Name*

First NameLast Name
Salutation
Example: Mr., Mrs., Ms., Dr.
Pronouons
Example: He/Him, She/Her, They/Them
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Home Phone
Birth Date*

MonthDayYear
Demographic Information
Ethnicity
Nationality
Business/Work Information
Title/Profession*
Company Organization*
Business Email
example@example.com
Business Phone Number
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Educational Background
What is your educational background?*
College(s) and/or University(s) Attended
Degree(s) and/or Major(s)
Trainings or Certifications
Other
Community Service and/or Memberships
Current professional and/or service organizations *
Current clubs and/or memberships*
Please list any community service or related awards you have received*
Have you ever been involved with other non-profit organizations?*

YesNo
If yes, please list organizations and type of involvement.
Additional Information
Please describe any experience you have had as a community member, donor or volunteer with VHF. How many year(s) have you been involved in some capacity?*
What do you think are the most important duties of a Board member?*
Why are you interested in serving on this Board?*
Describe how your skills and values will be an asset in serving on this Board.*
Our Board members are expected to attend four Board meetings each year, with several being in-person, as well as participate in regular conference calls, and attend a majority of special events. Will your schedule allow this level of participation? Are there times each month/year that you would not be available for meetings? *
Board members are asked to join one or more committees. If you become a part of the VHF Board, which areas of interest do you have based on your personal and professional skills?*
Please indicate which committees you would be most interested in joining if nominated to the Board*

AdvocacyDevelopmentFinanceGovernanceFinancial AssistanceProgramScholarshipOther
Please explain your choices*
Any additional information you feel would be helpful to share?
References

Please list two people, not related to you who have knowledge of your qualifications.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship*
Background Check
Some positions and roles require a criminal background check. If needed, would you consent to such a check?*

YesNo
Have you ever been convicted of a crime, or are you currently under indictment?*

YesNo
If yes, please explain.
I certify, by my electronic signature, that the information contained within this application and presented to the Foundation is accurate, true, and complete to the best of my knowledge. If selected for the Board of Directors, I agree to adhere to all Foundation policies, guidelines, and values. I agree to a criminal background check if required for my position and role, and agree to report any criminal indictments or convictions which may occur during my time on the Board.
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VHF Board of Directors Interest Form

Personal Information

Demographic Information

Business/Work Information

Educational Background

Community Service and/or Memberships

Additional Information

References

Background Check