All information is confidential and used only for board selection process
Mission: Our mission is to advocate for transformative and quality health care for patients with Sickle Cell disease. Please submit the completed documents and you will hear from the board soon after.
Name
*
First Name
Last Name
Preferred Salutation:
Mr. Mrs. Ms. Miss (Other: e.g., Dr.)
Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday:
-
Month
-
Day
Year
MM-DD-YYYY
Primary Phone Contact:
*
-
Area Code
Phone Number
Mobile (Cell) Phone:
*
-
Area Code
Phone Number
Best Email to Contact:
*
example@example.com
Employer:
Please provide the name of Employer
Title/Occupation:
Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone:
*
Office Phone (Area Code - Telephone Number)
Fax (Area Code - Telephone Number)
Board Member Personal Information Sheet:
Please list preferred contact methods only as an indication of permission to contact you for Board Member related information only
Marital Status:
(Married, Single, Engaged, Divorced, Widowed)
Spouse Name if applicable:
*
First Name
Last Name
Children Names and their ages if applicable:
Your Education: (State degree(s) and college(s)/university(ies) attended)
In addition to this Board Information Sheet, please attach or write a short descriptive Biography and include a link to your professional headshot photo for publishing.
Written Board Interview Questions
What makes the Sickle Cell Medical Advocacy Inc mission meaningful toyou?
Please list current boards on which you are currently serving or have served:
What skills, connections, resources, and expertise do you possess and are willing to use on behalf of the organization?
Are you able to commit to attending six (bi-monthly) board meetings eachyear? These meetings usually occur during the month of January, March,May, and July, September and November.Additional meetings may be required for organizational business.
Yes
No
Other
Please explain:
Are you willing to make a financial commitment to the organization through personal donations (whatever you can give; suggested starting donation is $10/month), soliciting donors, sponsors, or contributions, facilitating fundraisers, and participating in events that raise funds for the organization?
Yes
No
Other
Please explain:
What interests would you like to become involved in concerning the organization? Please place an X on one or more boxes.
President (Executive Board Member)
Secretary (Executive Board Member)
Treasurer (Executive Board Member)
Board of Directors
Covenant Financial Partner
Volunteer
Please list volunteer work or community organizations that you have worked with or committed to in:
Please list other interest areas, hobbies or skills that might be interesting for us to know about and you would be willing to leverage in the organization:
Thank you! Please add any other information you would like us to know.
Submit
Should be Empty: