Pennsylvania Association of Senior Centers (PASC)
Board of Directors Application
Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
*
-
Month
-
Day
Year
Date
Preferred Email
*
example@example.com
Work Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County where you work
*
Your Age
*
21-30
31-39
40-55
55-65
65-75
76+
What is your current Gender Identity?
Please Select
Female
Male
Transgender Woman
Transgender Man
Non-Binary
Two-Spirit
What is your Sexual Orientation?
Please Select
Lesbian or Gay
Straight
Bisexual
Two-Spirit
Other
Prefer not to answer
Are you a current member of PASC?
Yes
No
If yes, PASC member #
How long have you worked in the Aging Network?
*
Please Select
less than 1 year
1-3 years
4-6 years
70-10 years
11-15 years
16-20 years
Over 20 years
Were you referred by a PASC Board Member? If so, please provide their name.
What are your current associations and/or club affiliations? (Ex. Professional organizations, Rotary Club, Sororities, Fraternities, etc). If you are in a leadership role, include title.
Do you have any experience serving on a Board?
Yes
No
Please describe briefly. List any Boards you have participated on and your role.
Why would you like to be considered for service on the PASC Board of Directors?
*
What would make you an asset to the PASC Board?
*
Board members are asked to serve at least 1 full 2-year term. The PASC Board has 4 quarterly meetings per year: 3 are in person, one is the day before the annual conference. Board members are required to attend all 4 quarterly meetings. Is this something you are able to commit to at this time?
*
Yes
No
PASC requires each Board member to actively participate in at least 1 committee. Which committee/s are you most interested in?
*
Membership
Legislative
Professional Development
Public Relations
Committees meet online as needed between Board meetings. Is this something you are able to commit to at this time?
Yes
No
Is your employer aware of this application and supportive of your potential Board service?
*
Yes
No
Board members are asked to make a yearly donation of $100 to PASC. This can be from your agency or from the Board member personally. Are you able to make this donation?
*
Yes
No
Please upload a copy of your resume.
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PLEASE READ CAREFULLY: By signing below I acknowledge that I have read and meet the requirements to serve on the Pennsylvania Association of Senior Centers Board of Directors. I understand that this is an application and that applications are subject to review and approval by the Board.
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