Board Member Application

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Senior Connection Board Member Position Description

Acknowledgement(Required)

I have read the term and participation expectations and the board member responsibilities.

Name(Required)

First Middle Last

Cell Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other languages spoken (including sign language)(Required)

How did you learn about Senior Connection?(Required)

Brief Bio(Required)

TWO PARAGRAPH MAXIMUM

Which of the following fields do you have experience in? Check all boxes that apply.(Required)

Finance/Accounting

Fundraising

Legal

Marketing/Social Media

Local Government & Advocacy

Other

Other(Required)

Please describe your experience and how this would serve the mission of the organization.(Required)

TWO PARAGRAPH MAXIMUM

Please describe any previous or current experience with nonprofit boards(Required)

TWO PARAGRAPH MAXIMUM

Please list any degrees, licenses, certifications or other designations(Required)

TWO PARAGRAPH MAXIMUM

If approved for the board, the following information is necessary to run a background check.

Date of birth(Required)

MM slash DD slash YYYY

Gender(Required)

What date did you move into your home(Required)

MM slash DD slash YYYY

I hereby certify that all information I have supplied in this volunteer application is true, complete, and accurate. I understand that by submitting this application, I authorize inquiries to be made concerning my suitability as a volunteer and that this application is not a guarantee that I will be accepted as a volunteer with The Senior Connection. I also give permission for criminal background, three year MVA driving record check and other checks, if applicable. Further, I acknowledge that participation in any Senior Connection program as a volunteer does not constitute employment with The Senior Connection and that I am not covered by any type of Workers’ Compensation program while performing duties associated with volunteering. I understand that The Senior Connection does not unlawfully discriminate in employment or volunteer appointments and no question on this application is used for the purpose of limiting or excusing any applicant from consideration on a basis prohibited by applicable local, state, or federal law. I agree to comply with and be bound by the agency’s safety and health rules and regulations, rules of conduct, and any other policy and/or rule or procedure set forth by the organization.

Signature(Required)

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