TMB BOARD AND LEADERSHIP SERVICE INFORMATION FORM

TMB BOARD AND LEADERSHIP SERVICE INFORMATION FORM
Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company
Position
What volunteer opportunity are you interested in (check all that apply):

Board ServiceCommittee ServiceOrganization VolunteerOther
Briefly describe your interest in The Milk Bank, please include goals you may have for sharing time, talent, treasure, ties, or testimony along with any prior non-profit service experience.
What is your primary industry/expertise (check one):

Accounting/Banking/FinanceBusiness/EntrepreneurialContractor/FacilitiesEducationFundraising/SalesGovernment/PolicyHospitalityTechnologyHuman ResourcesInsuranceLegalMarking/Public Relations/MediaMedical/HealthcareNon-ProfitOther
Committee Preference (Choose 1 or More):

AdvancementOperations/FinanceMedical AdvisoryGreatest Need
The Milk Bank carefully guards against conflicts of interest in both business and personal matters. Please disclose any possible, perceived or actual conflicts of interest here. Examples may include but are not limited to endorsement of specific products, relationships with clients/vendors of TMB, entities whose primary purpose is to develop, market, or sell products/services in service to infant formula, human milk substitutes, or for-profit milk banking as well as efforts that are detrimental to infant health, breastfeeding or health equity.
Please disclose any conflicts of interest:
Have you been referred by anyone currently engaged with The Milk Bank?

YesNo
Please list:
Upload: Please submit a résumé and bio if available

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Demographics (Optional)

The Milk Bank collects demographic data for reporting purposes and to combat disparities in healthcare. This information will not influence your application in any way.
I identify my race/ethnicity as (select all that apply);

Asian/Pacific IslanderHispanci/LatinXBlack/African or African AmericanIndigenous, Native American, or Alaska NativeWhite or CaucasianPrefer not to answerMy race and ethnicity is not listedOther
I identify my gender as:

FemaleMaleNonbinaryPrefer not to answerOther
Age

18 - 2425 - 3435 - 4445 - 5455 - 6465 or overPrefer not to answer
Special Stakeholder Group

Milk DonorMilk RecipientBereavementNICULGBTQIA+
Optional space for questions or comments:
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