Valley-Wide Board Member Application

Board Member Application

Please fill out the following information if you are interested in serving as a member of our Board of Directors.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business (Name, Title)
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Fax

Area CodeFax Number
E-mail*
How did you learn about Valley-Wide Health Systems, Inc.?*
What is your t-shirt size?*
Shirts are unisex sizes. Will be used for special shirt distribution throughout the year.
Each Board Member is required to attend the montly Board meeting, generally held on the last Wednesday from 5:00 - 9:00 p.m., and participate in at least two committees. Each committee meets as designated or as often as is necessary. For example, the Finance committee meets many times at 4:00 p.m., prior to the monthly Board Meeting.
Are you or any of your immediate family members currently employed by Valley-Wide Health Systems, Inc.?

YesNo
Are you a Valley-Wide Health Systems, Inc. patient/consumer?

YesNo
How many hours per month are you willing to commit to Board activities?
Which of the Board committees interest you?

PersonnelFinanceComplianceLegislativeExecutiveBoard Recruitment/RetentionContinued Quality Improvement Representative
Please give a brief description of any work or volunteer experiences you have had which might be relevant to serving on our Board. Have you ever been on any Board of Directors in the past?
Please tell us about yourself and why you are interested in joining our Board. This statement should be descriptive enough to introduce yourself to our membership, as it will be included in our election materials.
I understand that if I am extended an offer to become a Board Member for Valley-Wide Health Systems, Inc. it may be conditioned upon my successfully passing a background check and HHS sanction review.

We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, sexual orientation, marital status, genetic information or any other status protected by law or regulation. it is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on job-related factors.
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