Board Member Application

1. Personal demographics: please provide a form of I.D. (driver’s license, personal ID, etc.). In an effort to be inclusive and diverse, NAMI Kentucky is tracking the ethnicity of our board. Please share the following.
  First Name:
  Last Name:
  Address:
  City:
  State:
  Zip:
  Work Phone:
  Cell Phone:
  Home Phone:
  Email:
Preferred Communication Method:
Race: (check all that apply)            
  Age:
2. Current Work Status
Employment:        
If other, please explain:
  3. I am interested in serving on the NAMI KY board because:
  4. Board experience:

Please include name of organization, experience, position held (officer of the Board or at large), and dates served. List All current and past Board experience. Please check and date all that apply.

  5. Current and prior organization involvement:

List all the organization and/or associations you actively participated in. Include professional, social, religious, honorary, etc.

  6. Please list all volunteer experiences:

List organizations and volunteer area.

7. NAMI KY volunteer opportunities:

please check areas of interest and/or expertise

                   
                   
                   
                   
           
8. Check NAMI KY Board Committees on which you are interested in and willing to serve:

                               
  9. List hobbies, pastimes, etc.:

  10. Additional information:

(please note any possible or potential conflicts of Interest)

  11. Have you ever been charged or convicted of a crime?:

If so, please explain:

12. Have you taken and completed a 12 week Family-to-Family (F2F) class?:

       

If no, are you willing to take and complete a 12 week class within the next 12 months of serving on the board?


       
13. Additional Comments:

If accepted as a board member of NAMI KY, you will be required to travel across the state for our quarterly meetings. Mileage and lodging can be reimbursed.

  Full Name:
I certify that all infomation provided is corrrect: