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Board Membership Application
Dear Prospective Board Member:
DayStar Ranch, Inc. (DSRI) supports host ranches in NorthernCalifornia with the mission of empowering individuals with theknowledge and skills needed to live healthful lives with the use of horse activities and other horse associated services.Our vision is that all the DSRI’s host ranches throughout NorthernCalifornia will contribute to the unity and harmony within thecommunity in which they service through the promotion of horseassociated programs which focuses on healing, empowering, andstrengthening the individual as well as their relationships with family,friends, and the community-at-large.We thank you for your interest in becoming a trusted board member for DSRI. Enclosed is an application for you to complete and return prior to our Annual Board Meeting, which will be held on November 14, 2009.If you would like more information about DSRI, please visit our website daystarranch.org or call us at 530.529.2679.
DayStar Ranch ● P.O. Box 224 ● Red Bluff CA 96080 ● (530) 529-2679.
B
OARD
M
EMBER
A
PPLICATION
Name________________________________________________________ Date __________________________ Address_____________________________________________________________________________________ City_______________________________________ State___________________ Zip______________________ Home Phone_________________________ Work Phone_____________________ Cell Phone_______________ Emergency Contact Name __________________________________________ Phone______________________
S
KILLS
AND
I
NTEREST
(
APPLICABLE
TO
THE
BOARD
POSITION
)
………………………………………………………………………………………………………………..□ management□ public relations□ marketing□ fundraising□ special events□ community relations□ education□ training□ public speaking□ lobbyingCurrent occupation____________________________________________________________________________ Hobbies, skills, interests ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Previous board or committee experiences ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Please answer the following questions:
Will you attend regular meetings and special meetings?□ yes□ no
Will you attend a new member orientation? □ yes□ no
Would you consider a quarterly financial commitment of $ 25.00? □ yes□ no
A
VAILABILITY
………………………………………………………………………………………………………………..At what times are you available?Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays SundaysAM/PMAM/PMAM/PMAM/PMAM/PMAM/PMAM/PM
DayStar Ranch ● P.O. Box 224 ● Red Bluff CA 96080 ● (530) 529-2679.
B
ACKGROUND
V
ERIFICATION
………………………………………………………………………………………………………………..Have you ever been convicted of a criminal offense?□ yes□ noHave you ever been charged of neglect, abuse, or assault?□ yes□ noHas your driver license ever been suspended or revoked in any state?□ yes□ noDo you use illegal drugs?□ yes□ noDo you have any physical limitations or are you under any course of treatment which might limit your ability to perform certain types of work?□ yes□ no
List three names (along with their contact information) of individuals who can provide characterreferences. Include at least one professional reference.NameContact NumberRelevance______________________________________________________________________________________________________________________________________________________________________________________________________________________________
P
ERMISSION
TO
P
ERFORM
B
ACKGROUND
& R
EFERENCE
C
HECK
………………………………………………………………………………………………………………..I hereby allow Daystar Ranch to perform a check of my background, including
Criminal record
Driving record
Past employee/volunteer history
Personal references
Physician or TherapistI understand that I do not have to agree to this background check, but that refusal to do so may exclude me fromconsideration for some types of volunteer/board work.I understand that information collected during this background check will be appropriately limited to determiningmy suitability for particular types of volunteer/board work and that all such information collected during thecheck will be kept confidential.I herby also extend my permission to those individuals or organizations contracted for the purpose of this background check to give their full and honest evaluations of my suitability of the described volunteer/board work and such other information as they deem appropriateSign_______________________________________________ Date____________________________________ ………………………………………………………………………………………………………………..How did you hear about us?
Position description
Advertisement
Volunteer Center/Website Posting
Website
Family/Friend/Co-workers
Client of Agency
Employee of Agency
Other
S
IGNATURE
DayStar Ranch ● P.O. Box 224 ● Red Bluff CA 96080 ● (530) 529-2679.
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