LeadUS Mentoring Program 2015-16

Jefferson County Cancer Coalition Board of Directors Applicant Form

On behalf of the Jefferson County Cancer Coalition, thank you for your interest in joining our board. We are honored that you are considering sharing your time and talents with our organization. This application helps us learn more about your skills, interests, and what you would bring to our board, while also giving you insight into what matters to us. Our goal is to determine whether we are a good fit for one another and to create a meaningful, rewarding board experience. Thank you for taking the time to complete this application thoughtfully. We look forward to reviewing it and continuing the conversation.
Personal Information
Name*

Last NameFirst Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

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

MonthDayYear
Business/Work Information
Title/Profession
Company Organization
Type of Business/Organization
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list your current and past volunteer experiences including your length of service.
Boards, committees, task forces in the public sector (business, civic, community,religious, political, professional, recreational or social)
Public RelationsLegal ExpertiseEvent PlanningSocial MediaFundraisingProfessional Nonprofit ExperienceReading/Understanding budgets and balance sheetsPublic Speaking/PresentationsHR/AdministrationMarketingGrant WritingPublic Policy/AdvocacyStrategic PlanningWeb DesignInformation TechnologyOther
If you listed "Other," please explain.
Those committed to volunteering in a leadership capacity have an abundance of organizations to choose from. We are most appreciative of your interest in ours and would like to hear more. Why our organization and not any other? Please share your motivation and what it is about our mission that has led you to raise your hand to be a leading ambassador for us.
What excites you about the mission of the Jefferson County Cancer Coalition?
Please let us know if you have any specific fundraising or project ideas you would like to share.
CollaborativeRespectful of varying points of viewWilling and able to lead a discussionFacilitative styleEnthusiasticComfortable speaking in front of groupsManages time wellOptimisticResponsiveStrong work ethicGood sense of humorAsks tough questions with respect
Fundraising - Among other responsibilities, board members play a key role in raising funds for our organization. It is an expectation of board service that you will introduce people in your sphere of influence to our mission and invite them to know and do more - as prospective volunteers, board members, and donors. Can you speak to your level of comfort with this expectation?
Time - Board service is a true commitment of time and energy. We estimate that the board service could be a commitment of 4-10 hours each month. In addition, we ask for you to attend and actively participate in all scheduled meetings (second Monday of every month from 6pm - 8pm), serve on at least one committee, review materials in advance of meetings, participate in fundraising and donor outreach, and attend and assist with the Coalition's major events throughout the year. Board members are expected to serve on the JCOCC board for 2 years. Do you have any concerns or potential conflicts that may serve as impediments to this time commitment? If so, how will you manage the demands of your time?
Who recommended you for the JCOCC board?
Have you ever been convicted, plead guilty or plead no contest to a crime? (If yes, please explain)
Please identify at least two references we can speak with. List their name (first and last), relationship, and phone number.
After your application has been reviewed you may be asked to interview in order for us to better get to know you.

Thank you for your interest.

I certify, by my signature, that the information contained within this application and all supporting documents (i.e., resume, recommendation letters, etc.) is true, accurate, and complete to the best of my knowledge. An electronic signature is accepted.
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Jefferson County Cancer Coalition Board of Directors Applicant Form

Personal Information

Business/Work Information