Services de santé de Chapleau Health Services (SSCHS) Application for Membership Board of Directors/Board Committees 1. Instructions (a) To apply to be a member of SSCHS Board of Directors, you must complete this form and submit it with a copy of your current resume or a brief biographical sketch. (b) Please submit your completed form and resume or biographical sketch by mail, fax, or e-mail to the following address: (Chapleau Health Services, 6 Broomhead Road, P.O. Box 757, Chapleau, ON P0M 1KO Fax 705-864-0449 E-Mail (mdoyon@sschs.ca) (c) The deadline for applications is. (d) For more information about the application process, please contact: Gail Bignucolo, Chief Executive Officer, Tel: 705-864-3053 2. Applicant Contact Information Surname: First Name: Home Address: P.O. Box City: Province: Postal Code Home Phone Number: Business Phone Number: E-Mail Address: Preferred Method of Contact: Home Phone Business Phone Email 3. Eligibility Criteria and Conditions of Appointment (a) To qualify for nomination as a Director, an individual must be a member in good standing of the Corporation at the time of nomination and continue to be so during the term of membership on the Board and meet the following criteria: (b) No member of the Medical Staff of the Corporation shall be eligible for election or appointment to the Board of Directors except as where otherwise provided in the Bylaws. (c) No member of the Dental Staff of the Corporation shall be eligible for election or appointment to the Board of Directors except by resolution of the Board passed by a majority of the Board. (d) No employee of the Corporation shall be eligible for election or appointment to the Board of Directors except as where otherwise provided in this Bylaw, or if a former employee has not been employed by the Corporation for at least one year from the date of election or appointment. (e) Nor spouse, child, parent, brother or sister of any person included in (a), (b) or (c) above, nor the spouse of any such child, parent, brother or sister shall be eligible for election or appointment to the Board, except by resolution of the Board passed by a majority of the Board. (f) Directors must be at least 18 years old. (g) Undischarged bankrupts are ineligible to serve as directors. (h) A director is expected to commit the time required to perform board and committee duties. The minimum time commitment is likely 6-10 hours per month. (i) (j) Directors must fulfill the requirements and responsibilities of their position, for example, preparing for and attending board and committee meetings, upholding their fiduciary obligation to the hospital, and working co-operatively and respectfully with other board members. Directors must comply with the Public Hospital Act and other legislation governing the hospital, the hospital s bylaws and policies, and all other applicable rules. Directors must sign a Declaration confirming their agreement to adhere to their fiduciary duties and board hospital policies.
4. Conflict of Interest Disclosure Statement Directors must avoid conflicts between their self-interest and their duty to the hospital. In the space below, please identify and relationship with any organization that may create a conflict of interest, or the appearance of a conflict of interest, by virtue of being appointed to the board. 5. Knowledge, Skills, and Experience The board seeks a complementary balance of knowledge, skills, and experience. Please indicate your areas of knowledge, skills, and experience by completing Schedule A to this application. 6. Declaration By submitting this application, I declare the following: (a) I meet the eligibility criteria and accept the conditions of appointment set out above; (b) I certify that the information in this application and in my resume or biographical sketch is true. Signature: Date: Application for Membership: Schedule A Board of Directors/Board Committees I provide the following information with respect to my application for membership on the board. Name: Address: Business: Home: Telephone Numbers: Business: Home: Facsimile Numbers: Business: Home: E-Mail Address(es): Please list current or prior board experience: Which areas of board work are of particular interest to you? What skills/areas of expertise can you bring to the board? Please describe any linkages you may have had with various health care groups within the community: Please attach an up-to-date resume. Date Signature