Board Application

General Information - please review

1. Principles of Governance and Board Accountability
2. Roles & Responsibilities of the Board
3. Director/Officer Recruitment
4. Committees of the Board

Attachments

Please read and agree to the following:

1. Statement of Qualifiers for Board of Directors and Committee Members
2. Code of Conduct - Check back soon, under development
3. Conflict of Interest Policy

If you prefer to fill out the form through a Word document you can download it here.

Board Application Form

First Name*

Last Name*

Address*

City*

Province*

Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Postal Code*

Email Address*

Phone*

If you have previously served on or worked with a Board or Committee for a Non-profit entity please describe responsibilities and accomplishments briefly.

List other volunteer activities and your role.

Rate your skills/experience from 0-3 (0=none; 1=fair; 2=good; 3=advanced) for each of the following:
Governance Experience*

0=none

1=fair

2=good

3=advanced

Business Management*

0=none

1=fair

2=good

3=advanced

Human Resources Management*

0=none

1=fair

2=good

3=advanced

Clinical*

0=none

1=fair

2=good

3=advanced

Government and Government Relations*

0=none

1=fair

2=good

3=advanced

Strategic Planning*

0=none

1=fair

2=good

3=advanced

Construction and Project Management*

0=none

1=fair

2=good

3=advanced

Legal*

0=none

1=fair

2=good

3=advanced

Mental Health & Addictions Needs of our Region*

0=none

1=fair

2=good

3=advanced

Risk Management*

0=none

1=fair

2=good

3=advanced

Information Technology*

0=none

1=fair

2=good

3=advanced

Financial/Accounting*

0=none

1=fair

2=good

3=advanced

Change Management and/or Collaboration*

0=none

1=fair

2=good

3=advanced

Quality and Performance Management*

0=none

1=fair

2=good

3=advanced

Ethics*

0=none

1=fair

2=good

3=advanced

Client and Mental Health and Addictions Care Advocacy*

0=none

1=fair

2=good

3=advanced

Fundraising*

0=none

1=fair

2=good

3=advanced

Policy Development*

0=none

1=fair

2=good

3=advanced

Public Affairs and Communication*

0=none

1=fair

2=good

3=advanced

Equity, Diversity and Inclusion Initiatives*

0=none

1=fair

2=good

3=advanced

Demographic Information (Note: this information will be reported in aggregate, not individually) Please respond using wording that you are comfortable with.

Gender

Ethnicity

Member of a/an First Nation(s) and/or Indigenous Community:

Yes

No

Prefer not to answer

Sexual Orientation

Geographical Representation

What languages to you speak? (List in order of most comfortable)

Person with lived or living experience with mental health, substance use, and addiction? (family members included)

Briefly explain your interests in and/or concerns about our mental health and addictions system today.*

Is there any other information you would like us to be aware of with respect to your application including any skills that you believe can contribute to the Board's and Committee's work?

Please provide the names of two references (and their contact phone #) who would be willing to verify your application information*

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