Name *

First

Last

Home Phone Number *

Cell Number *

Address *

Email *

What is your tie to the CHI community? *

Briefly describe why you would like to join our Board of Directors: *

Your current organizational affiliations (names of the organization and your role(s): *

Your personal and professional networks (names of the organizations) that you are willing to introduce to CHI: *

Briefly describe your previous Board and other leadership experience: *

Which of your skills would you like to utilize on the Board? Check those that apply: *

• Board development
• Financial Management
• Training
• Strategic Planning
• Fundraising
• Marketing
• Staffing / HR
• Evaluation
• Volunteer management
• Program development
• Community networking
• Facilities management

Other skill(s) of yours that you would like to utilize?

What would you like to get for yourself out of your participation on the Board, e.g., what types of experiences, skills to develop, interests to cultivate for you, etc.?

Age

Gender

Ethnicity

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