YCAN Tripartite Board Membership Application

YCAN Tripartite Board Membership Application

Thank you for your interest in volunteering. Eligible applicants are residents of Park, Hot Springs, or Teton Counties age 18+. Please complete all questions below.
Board Service Acknowledgement
Before You Apply

Thank you for your interest in serving on the Yellowstone Country Assistance Network (YCAN) Board of Directors. Before completing this application, please review the following information.

Volunteer Service

Board service with YCAN is voluntary and unpaid by YCAN. Any compensation associated with an elected office or public appointment is separate from YCAN and is determined by the applicable government entity..
Are you willing to serve as an unpaid volunteer member of the YCAN Board of Directors?
Page 1 – Applicant Information
Preferred E-mail (required)
example@example.com
Full Legal Name

First NameLast Name
Preferred Name (optional)

First NameLast Name
Physical Address (Required)

Street Address

Mailing Address

CityState / Province

Postal / Zip CodeCountry
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred phone number (Required)

Area CodePhone Number
Date of Birth (18 years or older)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
County of Residence?

Other
How long have you lived in Wyoming?
How long have you lived in your current county?
Current Primary Role

(Required)
Which best describes your current status?

Other
Current Organization
If applicable, list your employer, government agency, business, or organization.
Current Position or Title
Examples: City Council Member (which city), County Commissioner (County), Executive Director, Social Worker, Banker, Teacher, Retired, Disabled, Volunteer, Homemaker / Caregiver
Organization Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Phone (optional)
Please enter a valid phone number.Format: (000) 000-0000.
Primary skills or experience you would bring to the Board (check all that apply):
Lived Experience
Board & Governance
Can you attend Zoom board meetings 4 times per year (typically 4th Tuesday at noon)?
What unique perspective or experience would you bring to YCAN's mission of addressing the causes and conditions of poverty in Park, Hot Springs, and Teton Counties?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you currently work for YCAN or receive pay from YCAN (employee or contractor)?
If yes: explain
Are you currently paid by, or on the board of, any organization that may apply for YCAN/CSBG funds or contracts?
if yes or not sure: explain
Do you or your organization have any agreement, MOU, or partnership with YCAN?
if yes or not sure:
Which Seat Are You Applying For?
Connection to YCAN's Service Area
Community Connection and Experience

Connection to YCAN's Service Area
Do you live, work, own a business, volunteer, hold public office, or otherwise have a meaningful connection to one or more of YCAN's service counties? *
If yes, which county do you have the strongest connection to and would be best able to represent on the YCAN Board of Directors?

Other
How are you connected to that county? (Check all that apply.)
Please describe your connection to Park, Hot Springs, or Teton County, including any employment, business, volunteer service, public service, civic involvement, or other activities that demonstrate your knowledge of and commitment to the community. *
Are you currently seeking, campaigning for, or holding an elected or appointed public office?
I understand that service on the YCAN Board may not be used to imply YCAN’s endorsement of any candidate, campaign, political party, or public-policy position.
If yes, identify the office and describe any potential conflict between your candidacy or official duties and service on the YCAN Board.
Community Voice (CSBG Low-Income Sector) Acknowledgement

(Required)
I understand that Yellowstone Country Assistance Network (YCAN) uses a separate democratic selection process for Community Voice (CSBG Low-Income Sector) representatives in accordance with applicable federal requirements, YCAN's Bylaws, and Board Policies.

I understand that submitting this Board Membership Application alone does not qualify me for appointment as a Community Voice representative. Applicants seeking to serve in the Community Voice sector must complete the required democratic selection process.

I understand that submitting this application does not guarantee an appointment to the Board of Directors. All applicants are evaluated based on eligibility, tripartite board composition, organizational needs, and available board vacancies. Directors are elected by the YCAN Board of Directors in accordance with the Bylaws.

I understand that submitting this application does not guarantee an appointment to the Board of Directors. All applicants are evaluated based on eligibility, the Board's current composition, tripartite sector representation requirements, organizational needs, and available vacancies. Directors are elected by the YCAN Board of Directors in accordance with the Bylaws.
Community Voice (CSBG Low-Income Sector) Acknowledgement
Why do you want to serve on the YCAN CSBG Tripartite Board? (short paragraph)
What community needs do you see most often in your county? (short paragraph)
Required Acknowledgements
I understand board meetings are public and minutes are recorded.
I agree to follow YCAN board Bylaws, policies, including confidentiality and conflict of interest.
I certify the information provided is true and complete.
Debarment / Fraud Certification (Required):
Please read each statement carefully.
Compliance Disclosure: Are you currently suspended, debarred, or otherwise prohibited from serving as a director, officer, or fiduciary of a nonprofit organization or from participating in state or federally funded programs?
If you answered “No,” please explain:
Volunteer Service & Eligibility Acknowledgement (Required)
Conflict of Interest Disclosure (Required):
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant Certification and Signature:I certify that the information provided in this application is true, complete, and correct to the best of my knowledge and belief. I understand that providing false or misleading information, or omitting material facts, may result in disqualification or removal if appointed.
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YCAN Tripartite Board Membership Application

Board Service Acknowledgement

Before You Apply

Volunteer Service

Page 1 – Applicant Information

Current Primary Role

Community Connection and Experience

Community Voice (CSBG Low-Income Sector) Acknowledgement

Required Acknowledgements