Board Member Application

Please fill out the following information if you are interested in serving as a member of our Board of Directors.

Each Board Member is required to attend the monthly Board meeting, generally held on the third
Tuesday of the month from 6:30 to 8:00 pm., and to participate in at least one committee. Each
committee meets as designated or as often as is necessary. Additionally, Board members are asked to
use LCHC services for their health care needs. (By law, 51% of our Board must use our services.)

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* 1. Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. How did you hear about the Health Center?

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* 3. Are you or any of your immediate family members currently employed by the Health Center?

Yes

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* 4. How many hours per month are you willing to commit to Board activities?

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* 5. What do you consider to be your interest or expertise?

Legal Affairs

Finance

Business

Health

Managed Care

Fundraising

Social Services

Labor Relations

Government

Site Preparation

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* 6. Please give a brief description of any work or volunteer experiences you have had which might be relevant to serving on our Board. Have you ever been on any Boards of Directors in the past?

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* 7. Please tell us about yourself and why you are interested in joining our Board. This statement should be descriptive enough to introduce yourself to our membership, as it will be included in our election materials.