BOARD MEMBERSHIP APPLICATION

BOARD MEMBERSHIP APPLICATION
For questions please contact: Anne Brewer, Executive Director
Early Learning Coaltion of Florida's Heartland,
Port Charlotte FL, 33948
Cell: (863) 558-1661 Email: abrewer@elcfh.org
Personal Information
Full Name:
Home Address:

Street Address 1

Dirección de la calle Línea 2

CityState

Zip Code
Personal Phone Number:
Format: (000) 000-0000.
Personal Email:
example@example.com
Employer Details
Employer Name:
Job Title:
Employer Address:

Street Address 1

Dirección de la calle Línea 2

CityState

Zip Code
Business Phone:
Format: (000) 000-0000.
Business Email:
ejemplo@ejemplo.com
My Employer is: (choose one)
My Employer Operates in (list all applicable counties/states):
What is your preferred contact preference?
Membership-Board Seat Type
Early Learning Coalition Board seats are established in 1002.83 F.S. Please indicate the applicable Board seat below.
Seat Type (choose one):
Do you currently have policy making or hiring authority in the above name business (or retired from said business)?
Do you or your families member receive income from childcare/ early learning programs?
Please indicate which type of program you currently work in:

Statement of Interest-Please tell us about your interest in becoming a ELCFH Board Member.
Community/Civic Involvement

Please list up to five community, civic, professional, business and/or other organizations with which you are or havebeen affiliated as a member and/or an officer
Organization 1
Dates of Membership 1
Offices/Positions Held 1
Organization 2
Dates of Membership 2
Offices/Positions Held
Organization 3
Dates of Membership 3
Offices/Positions Held
Organization 4
Dates of Membership 4
Offices/Positions Held 4
Organization 5
Dates of Membership 5
Offices/Positions Held 5
Race
Gender
Age
Veteran
Parent
Children's Ages
Do you require any special accommodation inorder to participate fully in the ELCFH businessmeetings? If Yes, specify.

Commitment and Operational Statements

Time Commitment: Serving as an ELC Board Member will require a commitment of time, including attendance at regular Board meeting and committee involvement, and may include visiting early learning program sites, ELC events, and becoming educated about many aspects of early childhood development and school readiness. Board meetings are generally held 4-5 times annually.

Conflict of Interest: A conflict of interest may occur when an item is presented for a vote that will directly affect you, your employer, your immediate family, or another organization with which you are affiliated. Conflict of interest issues generally requires you to disclose the conflict and abstain from discussion/vote on the matter.

Membership Requirements: Legislation specific to Early Learning Coalition Board composition requirements can be found in 1002.83 F.S. Locally developed policy for ELCFH governance can be found at www.elcfh.org- Board Member Resources tab. All new Board members are required to attend a new Board Member orientation.

Sunshine Law: The ELCFH is a legislatively mandated group and operates under the general Florida guidelines of the Sunshine Law (Section 286.011, F.S.) and Public Records Law (Chapter 119, F.S.)
Can you commit to regular attendance at Board and Committee meetings held generally held 5 times a year?
Please attach a copy of your resume.

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