Community Representative

BOARD STANDING COMMITTEE

COMMUNITY REPRESENTATIVE

CANDIDATE FORM

Muskoka Algonquin Healthcare is currently looking for individuals from the community, who due to the relevance of their expertise in a particular area, and interest in making a volunteer commitment to MAHC, could make a valuable contribution to the work of the Board as a non-director committee member.

If you are interested in serving as a Board Committee Community Representative, we ask that you complete and submit the following form along with a resume.

CANDIDATE INFORMATION

Name:
Mailing address:
City/Town: / Postal Code:
Phone (Home): / Phone (Mobile):
E-Mail Address: / Present Occupation:

Experience & Skills: Please check all that apply.

¨ Accounting/Financial / ¨ Government / ¨ Politics/Lobbying
¨ Business / ¨ Health Care / ¨ Public Relations
¨ Strategic Planning / ¨ Human Resources / ¨ Public Speaking
¨ Training/Education / ¨ Community Services / ¨ Social Services
¨ Entrepreneur / ¨ Legal / ¨ Facilities Management
¨ Biomedical Ethics / ¨ Management / ¨ Other (please explain):
¨ Information Technology / ¨ Other Board(s)

board committees: Please indicate the Board Committee that you would be interested in serving.

¨ Quality & Patient Safety / ¨ Governance
¨ Strategic Planning / ¨ Resources

Please explain why you wish to be considered for a position on the MAHC Board of Directors (attach additional pages if required)

Qualifications & Statement of commitment

I, the undersigned, hereby apply to be considered for as a Board Committee Community Representative, and in doing so, acknowledge and declare that: (please check each statement below to indicate your acknowledgement)
¨ I can regularly commit to 3-5 hours bi-monthly to prepare for and attend Committee meetings. (Meeting schedules vary and are provided in advance)
¨ I could, with notice, attend additional meetings when required.
¨ I will be committed to furthering the Mission, Vision and Values of Muskoka Algonquin Healthcare.
¨ I understand that if chosen to proceed through the interview process a Police Criminal Record Check will be required and any nomination will be contingent on the completion of this process.
¨ I will act honestly, in good faith and in the best interests of the Hospital and in so doing, support the Hospital in fulfilling its mission and discharging its accountabilities.
¨ I will offer constructive contributions to Committee discussions.
¨ Respect the views of other members of the Committee and the role of the Chair.
Signature / Date

Should you have any questions or concerns regarding this candidate form please feel free to contact the Board Liaison @ 705.789.0022 x 2342 or via e-mail @ .

Further information about Muskoka Algonquin Healthcare and the Board of Directors can also be accessed by visiting www.mahc.ca.

Please return candidate form along with a current resume to:

Muskoka Algonquin Healthcare

Nominations Committee

c/o Board Liaison Office

100 Frank Miller Drive

Huntsville, ON P1H 1H7

ADMINISTRATIVE USE ONLY:

Date form received:

Approval date: