Application Form for Board of Directors and Board Committees



Application Form for Board of Directors and Board Committees

Name: ____________________________________________

Address: ____________________________________________

Tel. Numbers: ____________________________________________

Email Address: ____________________________________________

Why are you interested in serving as Board member or Board committee member?

Please rate your knowledge, skills and experience in each category by checking (√) the most appropriate box.

|Knowledge/Skills/Experience In: |Capable In |Interested In |Fair |None |

|Business Management in a Complex Environment | | | | |

|Accounting / Finance | | | | |

|Construction / Architecture | | | | |

|Healthcare / Clinical | | | | |

|Research, Planning or Delivering programs for PHAs | | | | |

|HIV/AIDS Treatment, Research or Policy | | | | |

|Human Resources Management / Labour Relations | | | | |

|Law | | | | |

|Communications & Government/Public Relations | | | | |

|Governance | | | | |

|Client & Healthcare Advocacy | | | | |

|Fundraising | | | | |

|Capital Campaigns | | | | |

|MOHLTC Workings | | | | |

|Quality, Risk & Performance Management | | | | |

|Strategic Planning | | | | |

|Other (please specify) | | | | |

| | | | | |

Please attach a resume which outlines your knowledge, skills and experience in relation to governance at Casey House.

Please submit this application with a resume by Thursday April 10, 2014 to:

Attn: Heather Robinson Casey House 9 Huntley Street Toronto, ON M4Y 2K8

Fax: 416 962-5147 hrobinson@caseyhouse.on.ca

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