Board Member Application

*Required

We appreciate your interest in volunteering for service on the PCHS Board of Directors. Your application will be reviewed and upon Committee recommendation, an interview may be scheduled. Please note that submission of this membership application means that you are consenting to PCHS running a background check for regulatory compliance purposes.
Name:*
First Last
Occupation:*
Address:*
Street Address Address Line 2 City State ZIP Code
Email:*
Fax:
Personal Phone:
Business Phone:
Gender
- Male
- Female
- Nonbinary
- Decline
Age
- 18-34
- 35-49
- 50-64
- 65+
- Decline
Ethnicity
- Hispanic/Latino
- Not Hispanic/Latino
- Decline
Race
- American Indian or Alaskan Native
- Native Hawaiian
- Asian
- White
- Black or African American
- Pacific Islander
- Decline
Veteran Status
- Veteran
- Not a Veteran
- Decline
Housing
- Own/Rent Your Home
- Staying with Friends/Relatives
- Staying in a Treatment Facility
- Public Housing Where All Tenants Get Discount Rent
- Staying in a Shelter – Short-Term Housing Like the mission, YMCA, etc.
- Living on the Street, Outdoor, in a Car/Travel Trailer
- Living Somewhere Not Meant to be a Home-No Running Water/Heat
- Having Been Homeless in the Last Year and Have Housing Now
- Decline
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 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, or sibling through blood, adoption, or 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
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. 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
- Legal
- Financial Management
- Quality Management
- Clinical Relations
- 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 8:30 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. I understand that submitting this application means that I am consenting to PCHS running a background check for regulatory compliance purposes.
Electronic Signature:*
Date Signed:*
MM slash DD slash YYYY