Canyon Creek Services: Application for Board of Directors Membership                                      
Thank you for your interest in our organization! Please fill out this form accurately and thoroughly. 
Name *
Date *
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Email Address *
Phone Number  *
Please indicate if this is a work, home, cell, or other phone number. 
Were you referred to this application by a current Board or staff member? If so , who?  *
Board members may reside within or outside of our service area. Please select the county you reside in within our service area. If your area is not listed, please let us know where you reside, using the 'other' option. *
Required
Are you on other boards or committees that should be disclosed as a potential conflict of interest? *
What interests you about being a Canyon Creek Services Board Member?  *
Please list any professional or volunteer experience you feel would make you a good candidate for board membership.
 *
Please list the names and contact information for 3 references.  *
Our vision statement is 'Communities Free of Domestic Violence and Sexual Assault'. How would you represent or support our vision statement as a board member? *
Approximately how many hours a month would you be able to dedicate to your board member duties? *
Are you able/willing to attend monthly board meetings?  *
Required
Board members are asked to serve within a subcommittee. Which subcommittee areas interest you? *
Check all that apply
Required
Is there anything else you would like us to know when considering your application?
Do you have any questions regarding the Board Membership Agreement or the Board Membership Responsibilities (linked below)?
Signature *
By typing your name, you are digitally signing this document and affirm that:
  1. All of the information you provided is accurate and up-to-date
  2. You understand that board members are subject to a criminal background check
  3. You have read and understand the board membership agreement linked here: Board Membership Agreement
  4. You have read and understand the board membership responsibilities linked here: Board Member Responsibilities
Date of Signing *
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