THCC Board Application

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Date of Birth:*

Date

Gender*

MaleFemaleNon-BinaryPrefer not to answer

Race*

Ethnicity:*

Hispanic/LatinoNot Hispanic/Latino

Are you a patient of The HealthCare Connection?*

YesNo

Employment Status*

Full TimePart TimeRetiredNot Employed

Do you live or work in THCC Service areas? If so, where?*

Could contribute expertise in the following areas (choose all that apply)*

Related program experience:

Other areas of expertise bringing to the Board

Memberships/Affiliations

Volunteer Experience

Why are you interested in becoming a Board member of The HealthCare Connection? *

List names of any current or past Board members you know

FINANCE: Oversees development of the budget; ensures accurate tracking/monitoring/accountability for funds; ensures adequate financial controls; often led by the Board Treasurer; reviews major grants and associated terms; reviews year-end audit.

BYLAWS: Maintains Board terms. Recommends proposed candidates to fill vacancies and provides orientation and on-going training to Board members. Ensures effective Board processes, structures and roles, including retreat planning, committee development and Board evaluations.

DEVELOPMENT/PROMOTIONS AND COMMUNITY OUTREACH: Oversees development and implementation of the Fundraising Plan, identifies and solicits funds from external sources of support, working with the CEO and Development staff. Oversees development and implementation of the promotions and community outreach plans and gives advice on how to promote those plans.

QUALITY IMPROVEMENT: Oversees development of service delivery mechanisms; may include evaluation of the services; provides a link between the Board and the staff on activities and performance of those services.

STRATEGIC PLANNING: Responsible for identifying key issues that affect the organization by analyzing risks and challenges, establishing priorities and long-range goal setting. The committee reviews/evaluates the mission and vision of THCC, identifies goals and objectives, prioritizes projects, and develops other strategies as needed.

NOTE: While we will make every effort to match you with your selected committee(s), we cannot guarantee you will be appointed to that committee as we must consider available resources and individual committee needs.

First Choice*

Second Choice*

Signature*

Date*

Date

THCC Board Application

Board members are required by HRSA to provide their Social Security number upon appointment.

If you have specific memberships (e.g., in professional associations or committees), you can include those as well.

Committees

Committee Choice(s) – indicate first and second choice below.