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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