Board Member Application

Thank you for your interest in applying to become a member of the volunteer Board of Directors for Peninsula Community Health Services. The Nominating Committee of the Board will review your application at their next monthly meeting and might contact you for an interview. If there is not a position yet available on the Board, you might be invited to serve on one of the board committees.

Name:*

First Last

Occupation:*

Address:*

Street Address Address Line 2 City State ZIP Code

Email:*

Fax:

Personal Phone:

Business Phone:

Gender

Male
Female
Decline

Age

Ethnicity

Hispanic/Latino
Not Hispanic/Latino
Decline

Race

Veteran Status

Veteran
Not a Veteran
Decline

Housing

Qualifications

Members of the Board of Directors serve the organization either as someone who uses our services (a patient) or as someone who is a community representative (non-user). As a federally qualified health center (FQHC), our health center board of directors is required to have at least 51% patient representation. Someone who is the parent of a PCHS patient or who is financially responsible for someone who uses our services may qualify for the position providing patient representation.

No Board member may be an employee of PCHS or an immediate relative of an employee, including a spouse, parent, child, sibling, or any person related to those persons by marriage.

For which position do you qualify?*

If you qualify as the parent or the financially responsible party for a PCHS patient and are elected to the Board, we will need you to provide the name of the patient for our membership records.

Patient Representative
Community Representative

Please indicate if you are a PCHS patient or the financially responsible party of a PCHS patient.

If you are applying as a non-patient representative, does more than 10% of your annual income derive from the healthcare industry?*

PCHS’ governance policy defines the healthcare industry as “organizations whose primary purpose is the routine delivery of direct patient healthcare services.” FQHCs cannot have more than half of their non-patient board members receive income that exceeds 10% of their annual income from the healthcare industry.

Yes
No

Medicare Compliance

Within the last 10 years, were you convicted, plead guilty or no contest, or consent to a pretrial diversion to a felony?

Yes
No

Please check particular interests or specialty knowledge:

Business Management
Communication/Public Relations
Financial Management
Quality Management
Political Relations
Legal
Leadership/Strategic Planning
Other

The full Board relies on the work of our board committees and participation in one or more committees is expected. Please indicate your interest in one or more of the following:

Finance Committee: Meets and reports monthly to the Board. Provides oversight of the financials.
Quality Management / Compliance Committee: Meets and reports quarterly to the Board. Assists the Board in formulating and reviewing policies, engages in oversight to ensure clinical quality and safety, utilization management, and corporate compliance regarding the ethical conduct of the organization.
Community Advocacy Committee: Meets and reports to the Board bimonthly. Enhances and promotes community awareness and community relations through outreach, education, and marketing of the organization’s program and services.

Board Meetings

Regular Board meetings are currently held monthly on the third Wednesday of each month at 8:00 a.m. Meeting attendance is necessary for the Board to function cohesively and to be effectively informed. Although in-person participation is preferable, arrangements are made for telephone participation.

Are you able to attend monthly meetings?

Yes
No

Describe past or present experiences with PCHS:

Mission Statement: The mission of Peninsula Community Health Services is to provide accessible, affordable, quality health and wellness services for our communities.

What do you believe will be your major contribution to the PCHS Board of Directors?

What is your understanding regarding the responsibility of a non-profit board member?

I certify the information given in this application is true and complete to the best of my knowledge

Electronic Signature:*

Date Signed:*

360-377-3776

360-475-3729

866-418-1002

360-874-5595

360-377-3776

711

Board Member Application