Board Member Application

Layout

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Phone *

Qualifications

I, the undersigned, hereby apply to be considered for appointment as a Director of the South Bruce Grey Health Centre (SBGHC), and in doing so, acknowledge and declare that: *

I am at least eighteen (18) years of age;
I am not an undischarged bankrupt;
I am not a member of the credentialed staff or an employee of SBGHC;
I have not been a member of the credentialed staff or an employee of SBGHC within the preceding five (5) year period;
I am not related through family* or reside with a member of the credentialed staff or an employee of SBGHC;
I have a principal residence or carry on business within the area serviced by SBGHC (including the communities and surrounding areas of Chesley, Durham, Kincardine and Walkerton)

*Family Member includes spouse, parent, child, sibling of any person, and the spouse of any such child, parent, sibling, and includes the partner of any person.

Role and Responsibilities

Please download and review Board and Director responsibilities as outlined in the attachments below.

Roles and Responsibilities - Board

Roles and Responsibilities - Directors

Time Commitment and Frequency of Meetings

I confirm that I have reviewed the responsibilities assigned to the Board and individual Directors and express my willingness and ability to comply. *

I agree.

Skills, Experience and Knowledge

The South Bruce Grey Health Centre Board of Directors is skills based, and seeks a complimentary balance of such. The skills, experience and qualities of Directors are important elements in governance, and will be considered in nomination and election processes. Please identify specific skills and expertise that you could contribute to the Board. *

The Board seeks a complimentary balance of knowledge, skills and expertise. Please identify specific skills and expertise that you could contribute to the Board.

Please describe any other knowledge, skills or experience that you would bring to the Board.

Resume

Please attach your resume in a Word (.docx) or PDF (.pdf) format. *

Click or drag a file to this area to upload.

Conflict of Interest

Below I disclose my participation or affiliation with any organizations that may create an actual or perceived conflict of interest with the Corporation (if there are none, enter n/a or none):* *

Please describe why you are seeking a position on SBGHC's Board of Directors. *

Declaration

By submitting this application, I declare the following: *

I certify that the information in this application and in my resume is factual.
I authorize the release of my personal information as noted above to the Board of Directors Ad Hoc Nominating Committee and the President & CEO of South Bruce Grey Health Centre for the purpose of providing information regarding my application.