Application to become a Board Member

Fairbanks, Alaska

A local non-profit since 1988

Want to be a Board Member? Here is an application you can copy and paste, or one is available upon request!

Not sure if you want to join? We would love to have you at one of our Board meetings to sit in and see what it's all about. Email today with any questions, to get an application emailed or to see when the next board meeting is!

viavitahealthproject@gmail.com

VIA VITA HEALTH PROJECT, INC.

BOARD MEMBER APPLICATION

Name: _______________________________________________________ DOB: ____________

Address: _________________________________________________________________________

Phone #’s: ________________________________________________________________________

Email: ___________________________________________________________________________

SS#: ___________________________ Occupation: ______________________________________

Employer: __________________________________ Year Started? __________________________

Please share what the birth center means to you:

__________________________________________________________________________________

___________________________________________________________________________________

Have you ever been charged or convicted of any crime? ______ If so, please explain:

___________________________________________________________________________________

Please list any previous board experience and dates served, and any community involvement you feel is relevant:

_________________________________________________________________________________

Please list any skills you may have to contribute (e.g. fundraising, public relations, planning, financial, personnel, legal, programs, etc.)

________________________________________________________________________________

_________________________________________________________________________________

__________________________________________________________________________________

Why do you wish to serve on this board?

_________________________________________________________________________________

__________________________________________________________________________________

Do you have a personal or professional relationship with anyone who is employed at the birth center or on the board of Via Vita Health? ________ If yes, explain:

___________________________________________________________________________________

____________________________________________________________________________________

Please list 3 references including both 1st and last name as well as a contact number:

1._________________________________________________________________________________

2.__________________________________________________________________________________

3.___________________________________________________________________________________

I understand that Via Vita Health Project, Inc. is a non-profit organization and, if I am chosen as a member of the Board of Directors, I will represent it as such. As a board member of Via Vita Health Project, Inc., I will be responsible for the oversight and accountability of the operations of the corporation. It is my responsibility to remain informed on the operational and financial aspects of the business. I will make every effort to attend board meetings and to be an active, involved participant. I understand that neither I, nor any family member, may benefit financially or materially from my position on the board.

____________________________________________________ _________________________

Signature Date

Thank you for applying for a position on the Board of Directors of Via Vita Health Project, Inc.