Mimi’s House Foundation Leadership & Board Application

Mimi’s House Foundation Leadership & Board Application

Thank you for your interest in serving with Mimi’s House Foundation. This application is designed to help us maintain accurate records, ensure organizational compliance, and build a strong leadership team aligned with our mission of empowering young women through mentorship, behavioral health support, education, and life-planning services. Please complete all sections honestly and thoroughly.
Personal Information
Full Legal Name

First NameMiddle NameLast Name
Preferred Name / Nickname
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Position Information
Position Applying For
Department/Area of Interest

Other
Are You Currently Licensed or Credentialed?
Please List All Certifications, Licenses, Degrees, or Credentials
Professional Experience
Current Employer
Current Job Title
Years of Professional Experience
Professional Background Summary
Please Describe Any Experience Working With
Mission Alignment
Why are you interested in joining Mimi’s House Foundation?
What strengths would you bring to the organization?
Describe your leadership style
Are you comfortable working with justice-involved or at-risk youth?
Why is our mission important to you?
Compliance & Eligibility
Have You Ever Been Convicted of a Felony?
Please Explain
Are You Willing to Complete the Following Requirements?
Do You Agree to Maintain Confidentiality Regarding Participants and Organizational Matters?
Do You Understand That Any Misrepresentation May Result in Removal From Leadership?
Availability & Participation
Are you available for
Preferred meeting format
Estimated hours you can contribute monthly
Document Uploads
Upload Resume or Bio

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Upload Certifications or Licenses

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Upload Government ID for Verification

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References
Professional Reference #1 Name

First NameMiddle NameLast Name
Professional Reference #1 Relationship
Professional Reference #1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Professional Reference #1 Email
example@example.com
Professional Reference #2 Name

First NameMiddle NameLast Name
Professional Reference #2 Relationship
Professional Reference #2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Professional Reference #2 Email
example@example.com
Agreements
Code of Conduct Agreement
Conflict of Interest Agreement
Electronic Signature
Date

MonthDayYear
Date
Should be Empty:

Mimi’s House Foundation Leadership & Board Application

Personal Information

Position Information

Professional Experience

Mission Alignment

Compliance & Eligibility

Availability & Participation

Document Uploads

References

Agreements