Date: Date

Candidate Name and Contact Info:

Name: Name:

Address 1: Address 1:

Address 2: Address 2:

Phone Number:

Home: Home

Office: Office

Mobile: Mobile

Email:

Email: Email

Confirm Email: Confirm Email

Referal Source/Name:

Referal Source/Name: Referal Source/Name:

Do you know anyone that works at Child Focus? If yes, please describe connection.: Do you know anyone that works at Child Focus? If yes, please describe connection.:

Do you know anyone that works for or is affiliated with a competitor of Child Focus? If yes, please describe: Do you know anyone that works for or is affiliated with a competitor of Child Focus? If yes, please describe:

Please provide the follow information to assist in the candidate evalaution:

Candidate Qualifications: Candidate Qualifications

Special Skills / Interests: Special Skills / Interests

Professional/Personal Background:: Professional/Personal Background:

History of Giving, Volunteering and/or prior Board memberships:: History of Giving, Volunteering and/or prior Board memberships:

Personal Characteristics:: Personal Characteristics:

Areas of interest to Child Focus and its mission:: Areas of interest to Child Focus and its mission:

Other comments or specfic areas of focus and/or committee interest, Early Learning, Behavioral Health, Mkt/Development:: Other comments or specfic areas of focus and/or committee interest, Early Learning, Behavioral Health, Mkt/Development: