Board of Directors InquiryFill out the form below to be considered for a seat on the CHS Board of Directors. All fields are required.Questions? Email Heidi Gee or call 608-361-0311"*" indicates required fieldsStep 1 of 6 – Applicant Information0%Applicant InformationName* First Middle Initial Last Date of birth* MM slash DD slash YYYY Phone number*Email address* Enter Email Confirm Email Do you live or work in South Central or Southwest Wisconsin?* Yes NoWe’re sorry!You must live or work in Beloit in order to be considered for a seat on our Board of Directors! Return to the CHS home page Employment InformationCurrent employerPositionType of business/organizationMedical, business, nonprofit, etc. Patient StatusAre you currently a patient of Community Health Systems (CHS)? Yes NoAre you interested, or would you be willing to become a patient of CHS?Please note: Being or becoming a patient of CHS, Inc. will not determine your eligibility for becoming a board member! Yes No Board MembershipsPlease list boards and committees that you serve on, or have served on (business, civic, community, fraternal, political, professional, recreational, religious, social) – if applicable.List your past and current board membershipsClick the + icon on the right to add another line.OrganizationYour roleDates of service Add RemoveHow do you feel CHS, Inc. would benefit from your involvement on the Board of Directors? Skills, Experience, and InterestsList your skills, experience and interestsPlease select all that apply Finance/Accounting Special Events Nonprofit Experience Outreach/Advocacy Communication Education/Instruction Administration/Management Fundraising Policy Development Personnel/Human Resources Grant Writing Community Service Program Evaluation/Public Relations Other MiscellaneousAre there any special needs that you would like to discuss with the Board of Directors? Yes NoPlease provide detailsCommentsThis field is for validation purposes and should be left unchanged.