Board of Directors Application

Applicant Information

Today's date*

Name*

First Middle Initial Last

Date of birth*

Phone number*

Email address*

Enter Email Confirm Email

Do you live or work in Beloit?*

Yes

No

We'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 Information

Current employer

Position

Type of business/organization

Patient Status

Are you currently a patient at Beloit Area Community Health Center?

Yes

No

Are you interested, or would you be willing to become a patient at our Beloit clinic?

Please note: Being or becoming a patient of CHS, Inc. will not determine your eligibility for becoming a board member!

Yes

No

Board Memberships

Please 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 memberships

Click the + icon on the right to add another line.

Organization

Your role

Dates of service

How do you feel CHS, Inc. would benefit from your involvement on the Board of Directors?

Miscellaneous

Are there any special needs that you would like to discuss with the Board of Directors?

Yes

No

Please provide details

Phone

This field is for validation purposes and should be left unchanged.

Questions?

Applicant Information

We're sorry!

Employment Information

Patient Status

Board Memberships

Skills, Experience, and Interests

Miscellaneous

Contact Information

Clinic Hours

Beloit Clinic Location

Darlington Clinic Location