Board of Directors

Nomination Form

Before you begin: Do not complete this form for anyone other than yourself.

About the Foundation for a Healthy Kentucky: We are a nonprofit organization that aims to create an environment where every Kentuckian has what they need to live a healthy life. We want to make the healthy choice the easy choice. And to do that, we try to improve policies and programs on the state and local levels around our two focus areas: access to care and children’s health. Learn more about us here.

Name

First Name

Last Name

Personal Phone

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Office Phone

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Employer

if applicable

Job Title

Race/Ethnicity

optional

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County

Nominee Background Information

Commitment to the Mission & Willingness to Serve

The mission of the Foundation is to address the unmet health needs of Kentuckians. Please describe why this mission matters to you and why you want to join our Board of Directors:

Expertise

Please describe the experience and strengths you would bring to the work of the Foundation. Include expertise or experience relevant to: -Improving The social drivers of health -Access to healthcare policy -Investment and finance management -Community and civic engagement -Equity practice -Strategic resource allocation Include any experience in the successful operation of an organization dedicated to health promotion, health care access, or in filling social services and healthcare access gaps, or ensuring food and or housing security; as foundation, non-profit, or a public charity.

Diversity & Equity

The Board of Directors takes seriously their charge to represent the diverse interests of residents of the Commonwealth. Our goal is to embody diversity and equity practice. We aspire to have a Board representative of Kentucky’s geography, demography, and income. Please describe your personal commitment to these priorities.

Group Affiliations

Please list any group memberships or community activities you are involved in:

References

Name (personal reference)

First Name

Last Name

Organization & Title

Daytime Phone

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Name (professional reference if applicable)

First Name

Last Name

Organization & Title

Daytime Phone

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How did you hear about this opportunity?

If by referral, please include their name and email.