Board of Directors Application Form

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Birth Date*

Date

Gender Identity

MaleFemaleOther

Place of Birth*

Job Description*

Company*

Email

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work phone

Area CodePhone Number

Please list your current and past Board experiences:*

What are you current associations and/or club affiliations?*

Please list your skills and expertise:*

What is your educational background?*

Please describe in detail some of your greatest strengths and weaknesses:*

What do you feel is essential to ensure that the Board and staff are successful in attaining the goals for this organisation?*

What experiences, expertise, connections or resources would you bring to Home Assist?*

Please detail your interest in joining the Board:*

What type of Board tasks do you prefer?*

Please let us know if you have any specific project ideas you would like to propose:*

Have you ever been engaged in any specific fundraising efforts? If so with whom, how and what was the amount raised?*

The company board will initially have 3 standing committees: (1) Quality, Clinical and Governance, (2) Risk, Finance and Audit and (3) Quality Consumer Advisory Body. Please select on or more options in what you would be interested in joining:*

Quality, Clinical and Governance - monthlyRisk, Finance and Audit - QarterlyQuality Consumer Advisory Body - Quarterly

How much time would you have to dedicate to our organisation? (eg. hours, a week, month, etc)*

A board is an exciting and engaged working board. Board members are required to participate in a minimum of at least 1 committee meeting (as above), 11 monthly board meetings, 1 Annual General Meeting a year. Board members are expected to be timely and present at each meeting with a maximum of three absences. Between work within and outside of meetings, hours of commitment would vary from between approx 3 - 6 hours per month. Board members are also encouraged to participate in fundraising and development activities. Board members are expected to commit to the role for a minimum of one year. All meetings can be conducted in person, via phone or teams/zoom meetings. Will you be able to make this commitment to our organisation?*

YesNoMaybe

Directors are required to apply for a police check or workers screening card, Directors identification number and complete an insolvency check. Are you willing to obtain these?

YesNo

Directors are required to complete certain paperwork (i.e. Non-Disclosure Agreements and Code of Conduct forms). Are you willing to complete these documents?

YesNo

All Directors will be required to complete the Governing for Reform in Aged Care Modules via the commissions learning platform (ALIS). Are you willing to complete these modules?

YesNo

Please provide a photo of yourself to share with our members during the voting period:*

After your application has been reviewed you may be asked for an interview to better get to you know.

Please provide at least 2 references upon request.

Thank you for your interest.

I certify, by my electronic signature, that the information contained within this application and all supporting documents (i.e. resume, references) is true, accurate and complete to the best of my knowledge. *

Date

Form

Demographic Information

Business/Work Information

More About You