WEST MEDFORD COMMUNITY CENTER
Board Member Information Form
Personal Information
Date Completed
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Month
-
Day
Year
Date
Name
*
Last Name
First Name
Formal Title (e.g., Dr/Mr/Miss/Mrs/Mx)
Pronouns
Preferred Email for Board Correspondence
Personal Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
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Alternate Phone Number
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Demographic Information
This section is OPTIONAL. Please keep in mind that many funders request information regarding our Board Members' personal information to assess our Board diversity.
Date of Birth (Month/Day/Year)
Gender Identity
Ethnicity
Race
Business/Work Information
Title/Profession
Company/Organization
Email (if different)
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone
-
Extension
Administrative Assistant Contact Information. (if applicable)
Why are you interested in Board Service with WMCC?
Have you or your family/friends participated in any WMCC events, activities and/or programming in the last year? If yes, please list. If no, why not?
What expertise, skills and or experience do you hope to share with the WMCC organization by joining for Board Service?
Bragging Links: Please insert links to your Linked In or any resources you want to share that highlight your work
Headshot (Upload Here)
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Upload Bio (or insert LinkedIn link to your bio above)
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Thank you for your interest in serving the WMCC organization!
Once you application is submitted it will be reviewed by a current Board member. Please expect a response within one week regarding your completed application and next steps.
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