Board of Directors Application Fill out the form below to be considered for a seat on the CHS Board of Directors. All fields are required. Questions? Email Danica Keeton "*" indicates required fields Step 1 of 6 - Applicant Information 0% Applicant InformationToday's date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* 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 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 InformationCurrent employer Position Type of business/organization Patient StatusAre 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 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 No Please provide detailsPhoneThis field is for validation purposes and should be left unchanged.