Heart-Star-TM

Early Learning Coaliton Board Membership Application

Personal Information

First Name *
Last Name *

Home Address

Street Address *
Address Line 2
City
State
Zip Code
Home Phone *
Cell Phone
Fax
Email *

Emergency Contact

First Name
Last Name
Phone
Relationship

Employment

Name of Business/Organization *
Occupation/Position

Employment Address

Street Address *
Address Line 2
City *
State *
Zip Code *
Work Phone *
Work Cell
Work Email
Type of Organization

Community Involvement

Please list up to 5 civic, professional, business and/or other organizations with which you have been affiliated as a member and/or officer:

1 - Name of Organization and Dates of Membership
1 - Office/Position
2 - Name of Organization and Dates of Membership
2 - Office/Position
3 - Name of Organization and Dates of Membership
3 - Office/Position
4 - Name of Organization and Dates of Membership
4 - Office/Position
5 - Name of Organization and Dates of Membership
5 - Office/Position
Do you, any of your relatives, or your business entity have a substantial financial interest in the design or delivery of the School Readiness or VPK Program or other child care program?
If Yes, Please Clarify
Do you, any of your relatives, or your business entity work for, contract with, or serve as a vendor for any of the following agencies: Early Learning Coalition, Agency for Workforce Innovation, Department of Education, Public School district, or recognized accrediting agencies for public or private schools?
If Yes, Please Clarify
Statement of Interest: Why are you interested in applying for Board Membership? *
In what way do you believe the Coalition will benefit from your participation as a Board Member? *
Have you ever been convicted of a felony? *
If Yes, Please Clarify
Are you willing to be fingerprinted for background screening purposes? *
Can you commit to regular attendance at Board and Committee meetings held generally held 6 times a year? *
What is your preferred location for contact?
PLEASE NOTE: You must provide a copy of your resume as a part of this application, Thank You. *
Maximum file size: 16 GB