Form
Prospective Board Member Information
Thank you for your interest in contributing time and skills to the Emma Goldman Clinic. The information you provide is confidential. The Nominating Committee and Board of Directors will review the information. Please contact ​info@emmagoldman.com or by phone (319-337-2112) at the Clinic if you have any questions.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Background
Please detail your educational background
Work experience
Board/volunteer experience
In which of the following areas do you have experience or interest?
Rows
Experience
Interest
Accounting/Fiscal Management
Fundraising/Development
Medical/Health Skills
Not-for-profit Management
Education/Public Speaking
Legal
Human Resources/Personnel
Political Interests
Discuss your interest in serving on the Board of Directors
The Emma Goldman Clinic provides a full range of reproductive health services, including abortions care. Please comment on your ability to support these services.
The clinic also serves men and individuals with diverse expressions of gender and sexuality. Please comment on your ability to support this mission of the clinic.
Emma Goldman Clinic is committed to building a Board of Directors that reflects the communities most impacted by reproductive health inequities. We recognize that lived experience and identity can bring valuable perspectives to our governance and advocacy work. If you are comfortable, please let us know whether you identify as a member of one or more historically marginalized communities. This information is entirely optional and will be used only in aggregate to support our equity and representation goals. It will not affect your eligibility or evaluation as a board candidate.
References
Please list at least three references
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Submit
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