Board Member Application

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PERSONAL INFORMATION

Given Name(s)

Last Name

Email Address

Phone Number (day)

Address

City/Town

Province

Postal Code

Country

INTEREST

Outline the reasons for your interest in serving on the CLSL Board of Directors.

BOARD GOVERNANCE EXPERIENCE

Identify your previous involvement with or experience in governance and list any offices held, including the name of the organization, dates etc.

RELATIONSHIP IN CLSL

I am an employee/volunteer of CLSL

I am the spouse, common-law partner, child, parent, sibling of:

A member of CLSL staff

A member of CLSL volunteers

A member of CLSL clients

None of the above

Conflict of Interest: To your knowledge are there any other circumstances that may give rise to an actual, perceived, or potential conflict of interest that may impact upon your participation on the board of directors or its Standing Committees:

If Yes, then please describe below:

GENERAL SCREENING / APPLICATION QUESTIONS

Have your ever been convicted of a criminal offence for which you have not received a pardon

If yes, please provide details

I undertake to advise CLSL immediately in writing of any change in the information contained in this application

I fully understand that any errors or omissions in my application may result in my application being refused or my appointment being revoked.

I understand that if chosen through the nomination process, any nomination will be contingent upon the completion of: 1. A police criminal record check, including vulnerable sector screen 2. Completion of two supporting references

I can regularly attend monthly Board and Board Standing Committee meetings, knowing 5 hours per month is expected.

Optional: Applicant may voluntarily provide additional information describing their skills, qualities, experience, knowledge, and diversity (gender identification, age, disability, sexual orientation, Indigenous status, and ethnicity) for consideration. Please describe:

HOW DID YOU HEAR ABOUT THIS OPPORTUNITY

Please tell us how you learned of this opportunity:

Other (please indicate)

Community Living Sarnia-Lambton’s employment model has been shared and adopted by other communities across Ontario and even internationally.

Vision: A community where everyone is valued and can participate.

Volunteers are the bridge between the community and the services that we provide

Community Living Sarnia-Lambton has grown to support more than 400 children and adults with developmental and intellectual challenges.