BHSN Behavioral Health Services North, Inc. A United Way Agency - Serving our community since 1874 A United Way Agency
serving our community since 1874
     
 
 
 
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Application for Board Membership


PLEASE COMPLETE APPLICATION IN FULL;
AN INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.

PERSONAL INFORMATION
Name (Last, First, M.I.)
 Social Security No.
Current Address
 Home Telephone No.
Email Address
Current Employer (Name & Address)
 Work Telephone No.
Work Email Address
 
REQUIRED INFORMATION
To the best of your knowledge if elected, would you be able to serve for a full three year term?


In which county do you reside?
Committe meetings are typically held during late afternoon and early evening hours. Are you available to attend meetings during those times?


Board meetings are usually held the 4th Monday of the month in late afternoon. Are you available to attend?


Do you have transportation available to attend meetings?


Have you ever been employed by BHSN, the Northern NY Center, or the Mental Health Association?


Do you have any relatives employed by BHSN or serving on the BHSN Board of Directors?


If yes, list name(s) & relationship:
Are you a principal in or employed by a business or non-profit corporation that currently or in the last three years provided or exchanged goods or services of any monetary value to BHSN or to the agency's consumers?


If yes, please explain:
List other volunteer organizations and / or boards on which you have participated in the past three years:
If elected, on what date are you available to begin BHSN Board participation?
Is there anything that would prevent you from performing in a reasonable & safe manner the essential fuctions involved in the position of Board member or as an officer of the Board?


If yes, please explain:
Have you ever been convicted of a felony or a misdemeanor?
(Conviction does not necessarily disqualify applicant from participation but will be considered in relation to specific board requirements)


If yes, please provide date, city, state and explanation
Have you ever been debarred from working in a federally funded program, i.e. Medicaid, Medicare?


Do you have any knowledge of any criminal, professsional practice or employment related legal, professional or civil actions against you in progress or pending?


 
VOLUNTEER SKILLS
Indicate those areas in which you have employment or volunteer experience.
Computers/Technology Finance/Bankingbr
Law Human Resources/Personnel
Planning/Development Human Services
Health/Medicine Marketing/Community Relations
Construction/Engineering Education/Training
List other volunteer organizations and / or boards on which you have participated in the past three years:
Describe any specialized training you may have:
       
 
PROFESSIONAL AND ACADEMIC ACHIEVEMENTS
List professional, academic, business or civic activities, achievements and offices held.
You may exclude all information indicative of age, sex, race, religion, color, national origin, disability.
 
APPLICATION AGREEMENT

The confidentiality of all individuals being served by this Agency and Agency trade and business information is to be protected at all times except in cases as identified by Federal Confidentiality Guidelines. I understand and agree to follow the confidentiality guidelines of Behavioral Health Services North, Inc. ("BHSN") for all clients being served or wo have been served by the Agency and all trade and business information as I may learn of in my role as a member of the BHSN Board. I also understand that I am bound by this confidentiality after my term of service has terminated as well as during my term of service.

By signing this Board Application I declare that the infromation provided by me is compleate and true to the best of my knoledge
I have read and agree to the application agreement.
 

 

 
 
 
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