Thank you for your interest in becoming part of ...



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BOARD MEMBER APPLICATION

Thank you for your interest in serving on the Board of Directors of the Riverside County Community Health Centers (CHC) .On behalf of the Board, we wish to invite you to submit this application for Board membership. Please complete the information below and return to your clinic staff or mail to the address below. Please retain Page Two for your information.

Name: _______________________________ ___

First Last

Address:_________________________________________________________________________

Street City Zip Code

Telephone #s: ____________________________________________________________________

Occupation/Employer: _____________________________ Email:___________________________

Best way to contact you: ____________________________________________________________

1) Why do you want to join Community Health Center Board?

________________________________________________________________________________________________________________________________________________________

2) How did you learn of the opportunity to serve on the board? (check all that apply)

| |

|CHC Board Member____ Doctor____ Nurse____ Clinic Staff___ Friend____ |

| |

|Posted on Clinic Wall___ Other____(Please specify)_______________________________ |

3) What Healthcare Centers have you visited for services? (check all that apply)

Banning FCC ___ Corona FCC ___ Hemet FCC ___ Indio FCC ___

Jurupa FCC ___ Lake Elsinore FCC ___ Palm Springs FCC ___ Perris FCC ___

Riverside NHC ___ Rubidoux FCC ___

Once we receive your completed form, you will be contacted. If you have questions about this form or our process, please feel free to call our office (951) 358-5222. In the interim, we thank you for considering service as a Board member with the Riverside County Community Health Center Board.

Riverside County Health System - 4065 County Circle Drive Suite 304 - Riverside, CA 92504

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