Hotel Dieu and Kingston General Hospitals have integrated to form the Kingston Health Sciences Centre.  We are currently seeking interested members of our community and region to serve on the board of directors.

Applications can be received on-line, by mail, fax or e-mail.

Mail:  Kingston Health Sciences Centre - KGH Site, 76 Stuart Street, Watkins 2, Kingston, K7L 2V7

Fax:  613-549-6707

Email:  KHSCceo@kingstonhsc.ca

If you have questions regarding the application process, please call us at 613-548-6002.

If you are submitted your application on-line, it is important to note that most information transmitted over the internet is not secure, therefore, confidentiality cannot be guaranteed.  The following form has been created on SurveyMonkey using cloud-based software and the information is housed in the United States.  U.S. privacy laws would govern this information.  Your application will only be kept on the site until the selection process has been completed.

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* 1. Name

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* 2. Business Address

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* 3. Home Address

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* 4. Contact phone numbers and email

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* 5. Preferred method of contact

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* 6. Additional information

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* 7. I can confirm that I have board/executive experience and expertise in:

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* 8. The Governance Committee seeks a complementary balance of knowledge, skills and experience.  Please indicate your areas of knowledge, skills and experience by completing the following listing or by simply listing your skills in the other box and the end of this question.

  Basic Intermediate Advanced
Board & Governance
Clinical
Construction & Project Management
Diversity
Education
Ethics
Finance
Governance & Government Relations
Health Care Administration & Policy
Human Resources/Talent Management
Patient & Health Care Advocacy
Political Acumen
Patient & Health Care Advocacy
Quality & Performance Management
Research
Risk Management
Stakeholder Engagement
Strategic Planning

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* 9. Please list current or prior board experience

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* 10. Which areas of board work are of particular interest to you?

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* 11. Please describe linkages you have or may have had with other health care organizations in the community or region.

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* 12. Conflict of Interest Disclosure Statement
Directors must avoid conflicts between their self-interest and their duty to the Kingston Health Sciences Centre.  In the space below, please identify any relationships with any organization that may create a conflict of interest, or the appearance of a conflict by virture of being appointed to the board.

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* 13. Declaration Requirements

Applicants are required to review several important documents located on our website to support the application process.

By submitting this application, I declare that I have read the documents noted below and I accept the conditions as outlined.  I certify that the information in this application and provided in my resume or bio sketch is accurate.

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* 14. Resume / Bio Sketch

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* 15. Today's date

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