Date

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which of these skills would you like to utilize on the board? Check all that apply: *

Board Development

Strategic Planing

Financial Management

Fundraising

Community Outreach

Volunteer Management

Facilities Management

If you are selected to join the Board, can you commit to provide at least 2-4 hours a month in attendance to Board and Committee meetings, and that you do not have any conflict of interest in participating on our Board? *

Yes

No

If you are not selected for the Board or you ultimately decide not to join, would you like to be a colunteer to assist our oragnization in various ways that match your skills and interest? *

Yes

No

Maybe