Application to Become a Board Director - Brightshores Health System

* All fields are mandatory

Preferred Title*

MissMs.Mrs.Mr.Dr.

First Name* (required)

Last Name* (required)

Street*

City/Town*

Province*

Postal Code*

Telephone Home*

Telephone Work*

Telephone Mobile*

Your Email*

Qualifications*

I, the undersigned, hereby apply to be considered for appointment as a Director of the Corporation, and in doing so, acknowledge and declare that: (please check each statement below to indicate your acknowledgement

I am at least eighteen (18) years of age;I am not an undischarged bankrupt;I am not an elected or appointed official;I am not a member of the credentialed staff or an employee of the Corporation;I am not a related through family* to a member of the credentialed staff, an employee of the Corporation or a current member of the Board of Directors;I have not been a member of the credentialed staff or an employee of the Corporation within the preceding five (5) year period; andI have a principal residence or carry on business within the area served by the Corporation.

*Family Member means the spouse, parent, child, brother or sister of any person, and the spouse of any such child,parent, brother or sister and includes the Partner of any person.

Review of Director’s Responsibilities*
Download Schedule A here

I confirm that I have reviewed Schedule “A” to this Application and agree that, if I am appointed as a Director of the Corporation, I: (please check each statement below to indicate your acknowledgement)

will support the objects of the Corporation (see Schedule “A”);will advise the Corporation if there is a circumstance that would cause me to automatically vacate the office of Director (see Schedule “A”);will abide by the conflict of interest and confidentiality provisions governing Directors (see Schedule “A”);will abide by the Code of Conduct policy and sign the Code of Conduct Agreement upon becoming a Director and annually thereafter;will cooperate and assist the Board to fulfill its responsibilities to the Corporation (see Schedule “A”);will exercise my powers and discharge my duties as Directors as required by law (see Schedule “A”); andunderstand that I will not be compensated for my services as a Director, although I may be reimbursed for out-of pocket expenses incurred.

Skills, Experience & Knowledge*

The Corporation supports a skills based Board of Directors. The skills, experience and knowledge of each applicant are considered in the recruitment process. In addition, candidate attributes are considered that reflect the breadth, depth and diversity of the Grey and Bruce communities served by the Corporation. To assist the Corporation in establishing a Board that meets these objectives, please complete the following.

a) I have the skills or experience in the following areas: (please check all that apply)

FinanceBusiness ManagementHuman ResourcesHealth Care Administration and PolicyClinicalGovernment and Government RelationsPolitical acumenConstruction and Project ManagementLegalStrategic PlanningRisk ManagementInformation TechnologyEducationResearchQuality and Performance ManagementBoard and GovernancePublic Affairs and CommunicationsEthicsPatient and Health Care AdvocacyCommunity Involvement

b) My current or most recent occupation is*:

Resume

Please attach your resume in a word(.docx) or PDF(.pdf) format*:

Why do you want to be a Brightshores Board Member and what will you bring to the position?* (500 words or less):

Conflict of Interest*

Below I disclose my participation or affiliation with any organizations that may create an actual or perceived conflict of interest with the Corporation (if there are none, enter n/a or none):*

Declaration*

If my application is approved, I agree to act as a Director of the Corporation and, in my capacity as a Director of the Corporation, I shall at all times act honestly and in good faith, in the best interest of the Corporation and abide by the Corporation’s By-Laws and all governing legislation. I understand that the term that I may serve as a Director is to be determined. I fully understand that any errors in my application may result in my application for consideration as a Director being refused or my Directorship being revoked. I undertake to advise the Corporation immediately in writing of any change in the information contained in this Application.

I understand it is the policy of the Corporation to conduct reference and criminal background checks as part of the selection process. Permission is hereby given to the Corporation to investigate the references provided and conduct a background check.

Acknowledgment of statement above*:

I Agree

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