ACC Senior Services Board and Committee Application
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone #
Format: (000) 000-0000.
Business Phone #
Format: (000) 000-0000.
Cell Phone #
*
Format: (000) 000-0000.
Signature
*
E-mail
*
example@example.com
Mission:
To promote the general welfare and enhance the quality of life for our community by identifying, developing, and providing culturally sensitive health and social services for older adults.
Vision:
To create an array of services that help older adults sustain their independence and lifestyles.
Leadership Position(s) You Are Applying For
*
ACC Board of Directors (must apply for 1 or more committee(s) below)
Committee Only
Committee Name
*
Finance
Board Development
Care Center
GT/MTV
Fund Development
Audit
Life-Long Learning
Volunteer Services
Demographics (Optional)
Gender:
Male
Female
Race/Ethnicity:
Age:
Under 30
31-40
41-50
51-60
61-70
70+
1. Board Applicant: Can you attend a monthly Board meeting and two to three committee meetings per month?
*
Yes
No
2.Committee Applicant: Can you attend a committee meeting and/or sub-committee meeting each month?
*
Yes
No
3. Do you agree to use email, Zoom or other electronic means to conduct ACC business?
*
Yes
No
4. Why do you want to serve on the ACC Senior Services Board/Committee?
*
5. Please describe how you can contribute to ACC Senior Services a a Board/Committee member.
*
6. Would you be interested in serving on the Board of Directors for Meals on Wheels Sacramento County?
*
Yes
No
7. Knowledge, Skills, and Experience
A. Skills and Knowledge Please complete by indicating your level of expertise with 1 = no/low level 2 = working/medium level, 3 = high level
*
Rows
Your Level
Organizational Development
1
2
3
Budgeting/Financial Planning
1
2
3
Fundraising/Development
1
2
3
Strategic Planning
1
2
3
Business Planning
1
2
3
Real Estate
1
2
3
Non - Profit Board Governance
1
2
3
Human Resources
1
2
3
Investment Management
1
2
3
Marketing/outreach/Public Relations
1
2
3
Grant Writing
1
2
3
Law
1
2
3
Government Relations
1
2
3
Facilities Management
1
2
3
Row 1 Value
Row 2 Value
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Row 4 Value
Row 5 Value
Row 6 Value
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Row 8 Value
Row 9 Value
Row 10 Value
Row 11 Value
Row 12 Value
Row 13 Value
Row 14 Value
B. Program Areas of Experience Please complete by indicating your level of expertise with 1 = no/low level 2 = working/medium level, 3 = high level
*
Rows
Your Level
Healthcare/Medicine
1
2
3
Assisted Living
1
2
3
Financial Assistance Programs
1
2
3
Nutrition Programs
1
2
3
Education Programs
1
2
3
Senior Housing/Independent Living
1
2
3
Skilled Nursing Services
1
2
3
Senior Program Activities
1
2
3
Transportation
1
2
3
Community Outreach
1
2
3
Row 1
Row 2
Row 3
Row 4
Row 5
Row 6
Row 7
Row 8
Row 9
Row 10
Are you currently serving on one or more ACC committees and wish to reapply for only current committees?
Yes
No
If yes, specify committees.
Are you applying to serve on a new committee?
Yes - please complete questions 8 through 14
No - you may skip questions 8 through 14
8. What has been your relationship with ACC?
9. Please describe your current or most recent employment.
Back
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10. Other areas of experience that might be helpful to ACC Senior Services.
11. Have you ever served on governing Boards of other organizations?
Yes
No
If yes, identify roles and describe areas of responsibility.
12. Please list other affiliations (e.g. volunteer, civic, religious, professional, fund raising, etc.) that can be a resource for you as a Board/Committee member.
13. Please describe past and present community and personal activities (including experience with fundraising, working with volunteers, etc.).
Please upload a current resume and any additional relevant information. If you are unable to upload your resume' and/or other document(s), please mail to: ACC Senior Services ATTN: Executive Assistant 7334 Park City Drive Sacramento, CA 95831
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ACC Senior Services
7334 Park City Drive, Sacramento, CA 95831
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