Board Application
Section 1 -- Personal Information
*Last Name:
*First Name:
Social Security Number:

Not Required at this time
Email Address:
Address:
*County of Residence:
*City:
*State:            *Zip Code:
Phone Number: 
Fax Number:
Alternative Phone Number:
 
Requirements and Responsibilities
Primary roles are strategic planning, policy making, general oversight of those policies, and safeguarding the assets and program quality of the Corporation, and attending all meetings (or call in if you cannot attend). An additional role is participating in any public relations and fund raising the Board feels is necessary. A Board member does not have any responsibility for the day to day management of the operations. If a violation of ethics, breach of confidentiality or misconduct is observed by any member of the Board, it must be reported to the Chair of the Board immediately.
 
Section 2 -- Your Background
Do you have experience in the following areas? (Check at least two and all that apply)
  Board recruiting, selection, evaluating, development;
  Human Resources policies, staff development;
Finance/Facilties;
Executive Leadership;
Fund development (lobby/legislation/communication/fund raising);
Public relations (local presentations).
*Of the items checked above, please discuss experience (past and present boards and organizations, position, types of responsibilties, training/education)

*Have you ever worked for LifeSkills?
Yes No
If yes, in what position?   
When?
*Have you ever been charged or convicted of a crime?
Yes No
If yes, please explain:
*Have you ever had a substantiated child abuse charge?
Yes No   
*Could you regularly attend board meetings? (Usually the 3rd Monday of each month)
Yes No
Do you have any conflictes of interest? (e.g. Immediate family members employed or on contract by LifeSkills, relatives currently on the Board, product sales to LifeSkills.)
 
Section 3 -- Preferences
Program Interest (Check all that apply)
Mental Retardation / Developmental Disabilities
Mental Health / Mental Illness
Alcohol and Other Substance Abuse
Comments:
*Committees: (Rank in order of preference -- 1 being top preference, 6 being the lowest)
Finance Committee: (a) Recommend to the full Board the adoption of the annual budget, (b) Review and recommend accounting policies, (c) Monitor the financial position of the Corporation, (d) Procure and review an independent audit.
Personnel and Staff Development Committee: (a) Recommend personnel policies and compensatory plans, (b) assure policy implementation and staff development, ((c) Resolve rievances if the decision of the president / chief executive officer fails.
Nominating Committee: (a) Recruit, screen, interview and recommend nominees for election to the full Board, (b) Submit nominations for officers and standing committee members, (c) Evaluate member functions including but not liminited to conflicts of interest, professional and constructive behavior and attendance, as well as overall Board competency and performance, (d) Review, remind and recommend canes to by-laws.
Program Planning and Evaluation Committee: (a) Review efficacy of the existing programs, (b) Review adequacy of current services and needed additions or changes.
Other interests to volunteer time and expertise:
Public Relations
Fund Development
Other (Please Specify):
 
Section 4 -- References (List at least three with complete names, addresses, and phone numbers)
Reference #1
*Name:  
*Address:  *City:   
*State:  *Zip Code:  *Phone Number:
Reference #2 
*Name: 
*Address:   *City:  
*State:  *Zip Code:  *Phone Number:
Reference #3 
*Name: 
*Address:  *City:  
*State:  *Zip Code:  *Phone Number:
*Why do you wish to be on the LifeSkills Board of Directors?
Your Application Date: 2019-02-19