Gila Regional Medical Center Board of Trustees Candidate Application

Full Name

Email Address

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Physical Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Why are you interested in serving on the Board of Trustees?

What experience, characteristics, or qualifications do you possess that would enable you to effectively serve?

Professional Reference 1 - Name

Professional Reference 1 - Email

example@example.com

Professional Reference 1 - Contact No.

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

Professional Reference 2 - Name

Professional Reference 2 - Email

example@example.com

Professional Reference 2 - Contact No.

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

Professional Reference 3 - Name

Professional Reference 3 - Email

example@example.com

Professional Reference 3 - Contact No.

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

QUALIFICATIONS RELEVANT TO HOSPITAL GOVERNANCE
My professional experience and background provide preparation for effective board-level oversight, including experience with organizational governance, public or nonprofit accountability, regulated environments, financial review and risk assessment, policy-level decision-making, and executive oversight, as sustained in my included résumé.

ALIGNMENT WITH GRMC MISSION AND VALUES
I support GRMC’s mission of providing exceptional, patient-centered care and am committed to governance that reflects the organization’s values of Integrity, Compassion, Accountability, Respect, and Excellence (I.C.A.R.E.).

UNDERSTANDING OF TRUSTEE ROLE & LEGAL RESPONSIBILITIES I acknowledge and accept that the role of a GRMC Trustee is one of oversight rather than management. I understand and am prepared to fulfill the legal and fiduciary responsibilities of trusteeship, including the duties of care, confidentiality, and conduct. I recognize the Board’s responsibility for oversight of quality and patient safety, financial performance, executive leadership support and evaluation, organizational compliance and conduct, as set forth in applicable state and federal statutes and regulations, including but not limited to the NM Inspection of Public Records Act, the NM Governmental Conduct Act, the NM Open Meetings Act, and HIPAA. By initialing here, I acknowledge I have read and accept trustee role & legal responsibilities:

BOARD CONDUCT, ACCOUNTABILITY, AND ETHICS In fulfilling trustee responsibilities, I commit to approaching responsibilities in the spirit of a trustee on behalf of the community and organization; maintaining loyalty to GRMC; supporting Board decisions internally and externally; offering opinions honestly, constructively, and respectfully; maintaining confidentiality and ethical conduct; avoiding conflicts of interest; and remaining accountable to the Grant County Board of Commissioners and the community. I further acknowledge that I possess the willingness, capability, and competency to use GRMC-issued email for Board communications and to access and utilize the designated digital portal for all Board documents. I agree to keep access to these applications confidential, secure, and used solely for official Board purposes. By initialing here, I acknowledge I have read and accept the above expectations:

STATEMENT OF GOVERNANCE INTEREST I am applying for an appointment to the Gila Regional Medical Center (GRMC) Board of Trustees with the intent of serving as a fiduciary steward and governing trustee of Grant County’s publicly owned, not-for-profit hospital. I understand that the Board of Trustees serves as the governing body of GRMC and is accountable for ensuring high-quality patient care, financial integrity, regulatory compliance, and alignment with the hospital’s mission, vision, and values. By initialing here, I acknowledge I have read and accept Statement of Governance Interest:

PARTICIPATION, PREPARATION & CONTINUOUS IMPROVEMENT If appointed, I am prepared to attend meetings on time and well-prepared, actively participate, serve on Board committees as needed, pursue ongoing trustee education and training, and communicate respectfully with physicians and medical staff, including participation in physician-related committee work when appropriate. By initialing here, I acknowledge I have read and accept stated expectations:

APPOINTMENT & REMOVAL ACKNOWLEDGEMENT I acknowledge that appointment to the Gila Regional Medical Center Board of Trustees is made by the Grant County Board of Commissioners pursuant to applicable provisions of the New Mexico Statutes Annotated. I understand that service as a Trustee is subject to the qualifications, duties, and standards of conduct established by law and governing authority, and that a Trustee may be suspended or removed from office only as provided by applicable law, including Sections 4-48A-6 and 10-4-1 through 10-4-29 NMSA 1978.By initialing here, I acknowledge I have read and accept Appointment & Removal Acknowledgement:

APPLICANT CERTIFICATION I certify that the information provided is accurate and that I am willing and able to fulfill the duties of a GRMC Trustee in accordance with applicable laws and governance standards. I understand the expectations of the role, and can perform these duties with or without reasonable accommodation. I agree to promptly notify the Board Chair or Vice Chair if I become unable to continue meeting these responsibilities and, if necessary, will voluntarily resign. Applicant Certification - Signature

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