Rural Health Network of South Central New York Board of Directors Application

Rural Health Network of South Central New York Board of Directors Application

(Revised July 2020)
Name

First NameLast Name
Personal (home) Email
example@example.com
Cell Phone

Area CodePhone Number
Home Phone (if different)

Area CodePhone Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Business Email
example@example.com
Business Address

Business Name

Street Address

CityState / Province

Postal / Zip Code
Business Phone

Area CodePhone Number
Business FAX

Area CodePhone Number
Preferred Methods of Communication (Please select Phone, Email, and Address)

Other
Rural Health Network SCNY's status as a Medicaid Billing entity with NY State will be finalized soon. As a Member of the Board of Directors, you will be required to provide the following information as per NY State Policy 504.1: Date of Birth, Social Security Number, Employment details for the past 5 years. All information will be kept secure at RHN, and only the Executive Director and Finance Director will have access. Do you agree to provide this information?
What expertise and/or experiences could you contribute to the RHN? (i.e. – advocacy, community partnerships, financial management, fundraising, evaluation, legal perspective, business/ program development, public relations, working with and/or representing rural communities etc.)
Do you have concerns about rural health for your county/region?
Do you have any ideas about opportunities for collaboration or partnerships with the Rural Health Network of SCNY?
The Network has four board officer positions and several committee leadership (chair) positions. If nominated, would you be willing to consider a committee chair or co-chair assignment? Committee Chair positions are listed below:

Other
The Network has four board officer positions and several committee leadership (chair) positions. If nominated, after a year or two of board service would you be willing to consider a Board Officer Position? The Board Officer positions are listed below:
Please list any relevant volunteer & professional affiliations*
List Organization/Activity* and Length of Service
Please list any Degrees earned and Name of Educational Institution
Do you have any initial ideas, concerns, or questions?
In the event you do become a member of the Board of Directors, how would you like your name (and credentials if applicable) to be shown on public documents and fund raising materials:
*Please attach your resume to the application, if available.

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We, the Governance Committee of the Board of Directors of the Rural Health Network of South Central New York, appreciate your interest in becoming a Board member. We ask that you take a moment to consider if you can commit to serving in this capacity for a three year term.

By signing below, you are acknowledging that you have read the Board Member Position Description and that you are committed to serving as an active, contributing member of the Board of Directors of the Rural Health Network of South Central New York as described.
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