Emerging Leaders Application/Nomination Form

This form can be submitted as a personal application or even to nominate a colleague. Applicants should complete the related sections and the reference field (excluding the nominator field). If you are nominating someone else, you should fill out the nominator section, along with as much info about the nominee as possible.

Please note: this is a competitive process, so we strongly encourage applicants to devote time and care to the application!

Reducing racial inequities that exist in our community. Please see question below. *

The goal of reducing racial inequities that exist in our community is a high priority for BHCHP and we aim to play a vital role in helping to reduce inequities and create equal outcomes for everyone. In your experience, what concepts are important to consider when approaching the work of the board that will impact diverse populations and low-income communities? What specific experiences have you had that might prepare you for such work as a member of the board?

References

Personal References		Order
	Name and Title * Reference Organization/Institution * Reference Telephone * Relationship to you * (i.e. supervisor, co-worker) Email Address, preferred *	Weight for row 1
	Name and Title * Reference Organization/Institution * Reference Telephone * Relationship to you * (i.e. supervisor, co-worker) Email Address, preferred *	Weight for row 2
	Name and Title * Reference Organization/Institution * Reference Telephone * Relationship to you * (i.e. supervisor, co-worker) Email Address, preferred *	Weight for row 3

Please enter 2 references - use the Add Another Item button to enter reference #2. Thank you.

Nominator Information

Only fill this section out if you are submitting an application as a nomination for someone else.

Nominator Address

Street Address

Street Address 2

City

State

ZIP code

Country

Leave this field blank