Board Application Form

General Information

Demographic Information

The demographic information below is requested to assist the Foundation in its efforts to develop a pool of nominees that is diverse and broadly representative of the communities we serve.

Are there other aspects of diversity about which the applicant would like the foundation to be aware?


Where did you learn about the Foundation?

Current Employment

May we call this employer for reference?

Employment History

Please attach a copy of your resume including the following:
• Work History
• Educational Background
• Non-profit Volunteer Service
• Civic Service

Statement of Interest

Please provide brief statement (500 words or less) detailing:
• Your interest in serving on the REACH Board of Directors
• Your experience most relevant to service on the REACH Board of Directors
• Your availability to commit to a minimum of 10 hours per month of service in the form of board meetings, committee meetings, and tasks as assigned or requested

Elected Official Eligibility

Are you currently serving as an elected or appointed official of a city, county, state or federal unit of government, or do you intend to file as a candidate for such a position in the next three years? Note: Elected officials are eligible to serve on the Board if their elected position is uncompensated or only nominally compensated.

Conflict of Interest

In light of other activities or positions that you hold, do you think there could be a conflict of interest related to serving on the REACH Board?

Background Check

Have you ever been convicted of a felony?

Are you willing to allow REACH to conduct a comprehensive background check if elected to the Board of Directors?

Statement of Commitment

I am fully prepared to dedicate the time and energy to serve on the REACH Healthcare Foundation Board of Directors. I will attend meetings regularly and serve as an active and involved member of the Board. I will serve with the utmost integrity and sensitivity to the health care needs of the citizens of this community. I am willing to abide by the Board’s Conflict of Interest Policy and to annually complete a Conflict of Interest Disclosure Statement. I will abide by the Board of Director’s determination should a conflict of interest arise. I have no history of activities, illegal or otherwise that would cause embarrassment to the Board. The information that I have submitted in this application is true and accurate to the best of my knowledge.

I understand the statement of commitment.

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