2020 Missouri Health Care for All Board Application Thank you for your interest in leadership of Missouri Health Care for All. Please click Submit to send this application. A member of our Board or Staff will be in touch about the status of your application. Our Board of Directors is looking for new members to help advance our vision of quality, affordable health care for all Missourians. To help us elect the best possible slate for the organization, interested potential board members are asked to complete this application. We will review all of the received applications and nominate a slate that brings the greatest strength possible to the board. Before applying, please be sure you have read about the responsibilities of MHCFA Board members at https://mohealthcareforall.org/seeking-board-members/. Applications for this round of elections are due by 5:00 pm Central Time on Friday, July 31, 2020. Thank you for your interest! Question Title * 1. Interview? Yes Question Title * 2. Name and Contact Information: Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title * 3. Please select one: I am interested in joining the Missouri Health Care for All Board of Directors representing my congregation, organization or faith tradition. I am interested in joining the Board as a community volunteer. Please specify organization, if applicable: Question Title * 4. Please describe your interest in being part of Missouri Health Care for All's leadership. Why, of all the places where you could volunteer your time, do you want to serve on this Board? Question Title * 5. Have you previously been involved with Missouri Health Care for All? If so, how? Question Title * 6. 3. Please share a brief biography. What do (or did) you do for work? Are you currently working, in school, retired, etc? Do you have personal connections to this organization or our mission? What else can you share that would help our current board members get to know you? (Please feel free to upload your bio using the next question if that is easier.) Question Title * 7. Alternatively, please upload a narrative biography (not a resume or CV, please). DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Alternatively, please upload a narrative biography (not a resume or CV, please). Question Title * 8. Please tell us about other organizations where you have volunteered or served as a board member (current or past). Question Title * 9. 5. Have you had prior experience with antiracism work, either as an individual or within an institution? If so, please tell us a little about it. Question Title * 10. Please check all constituencies to which you belong: Low-income Missourians Rural communities Urban communities Black Americans Hispanics/Latinx Americans Immigrants People with disabilities People with mental illness Parents of Minor Children Union/labor Movements People who are uninsured or underinsured Health care providers Faith leaders Business Owners or Leaders LGBTQ Community Other (please specify) Question Title * 11. What particular skills, interests, or experience can you contribute to Missouri Health Care for All? Question Title * 12. With which of the following aspects of our work would you be most interested in assisting? Mobilizing individuals and organizations (grassroots organizing) Organizational governance Financial management Policy analysis Public education Fundraising and development Antiracism work Other (please specify) Question Title * 13. (Disclosure of potential conflicts of interest)Are you directly or indirectly affiliated with a health provider or health insurance company? Please disclose if you work, lobby or serve as a board member of a health care company, insurance company, hospital, or other medical provider. No Yes (Please describe) Question Title * 14. If you are not selected for board leadership, are you interested in working with Missouri Health Care for All in other ways? Yes No Unsure Comments: Question Title * 15. I submit this application for the Board of Directors of Missouri Health Care for All. I attest I have reviewed the responsibilities of MHCFA Board members and am willing to fulfill these responsibilities, including making a time commitment of approximately 5-10 hours per month. I have answered the questions above completely and truthfully. Name: Date: Submit my application