Board Director Application Form - Grand Bend Area Community Health Centre

Date *

First and Last Name *

Address *

Address

City

Province

Postal Code

Home Phone *

Work Phone

Email *

Select the postal code(s) in which you live and/or work. *

Do you use the GBACHC primary care (clinical) services? *

Yes

No

Are you or have you been a client of any GBACHC service, program or community health group? *

Yes

No

Have you volunteered at the GBACHC? *

Yes

No

Describe your GBACHC volunteer work.

What is your occupation? *

Select the your connection(s) to the Grand Bend Area community. *

Describe your community connections selected above. *

Select your skill area(s). *

Describe your skill area(s) selected above. *

Select the area(s) in which you could assist with advocacy. *

Why would you like to be a GBACHC Board Director? *

Describe why you support the GBACHC vision, mission, core values and tagline. *

What are some of the health and social issues facing Grand Bend and area residents today? *

Outline your Board experience including the organization(s) mandate, length of time serviced and any offices held. *

Describe the strengths you would bring to the GBACHC Board. *

Upload your resume. *

Maximum upload size: 134.22MB

Directors of the GBACHC Board typically contribute four to six hours per month attending meetings and events. Please comment on your ability to commit to this amount of time. *

Provide the name, phone number and email address for two (2) references. *

Thank you for your interest in becoming a Director of the Grand Bend Area Community Health Centre (GBACHC) Board.