Board of Directors Application

Gardner Health Services always welcomes individuals who are interested in joining our Board of Directors. As a Board member, you can use your skills and talents to help fulfill Gardner’s mission.

"*" indicates required fields

Full Name*

First Name Last Name

Address*

Home Phone Number

Work Phone Number

Mobile Phone Number*

Email Address*

Place of employment or other point of contact*

Do you currently use Gardner’s services?*

Yes

If yes to above question, which health center?

Date you started receiving services from us

Date of most recent appointment

I was referred by

1. I am interested in becoming a Board Member because:*

2. Qualifications and/or qualities that I feel make me a viable Board Member candidate:*

3. Past or present membership in advisory groups, organizations, etc. (list dates):*

Date 1

Date 2

Date 3

4. A. Are you related to any current Board Member by blood or marriage?*

Yes

4. B. Are you related to any current employee of this organization by blood or marriage?*

Yes

5. List 3 references other than family and include their phone numbers with area code. Or, attach 3 letters of recommendation.*

List References

Attach 3 Letters of Recommendation

Reference #1

Full Name*

Address*

Occupation*

Phone*

Reference #2

Full Name*

Address*

Occupation*

Phone*

Reference #3

Full Name*

Address*

Occupation*

Phone*

Attach 3 Recommendation Letters

Attach Recommendation Letters 1-3*

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Experience:

6. List educational background degrees, etc. If available, please upload resume below.*

Upload resume

Drop files here or

Max. file size: 256 MB, Max. files: 2.

Signature*

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

GET IN TOUCH

Gardner Health Services Corporate Office 160 East Virginia Street, Suite 100 San Jose, California 95112

Info@gfhn.org
Medical Appointments 408.457.7100
Dental Appointments 408.457.7102
Mental Health 408.287.6200
WIC 408.254.5197
Human Resources 408.918.2618
Corporate Fax 408.278.7799

MEDICAL RECORDS

Medical Records 408.579.6112
Medical Records Fax 408.579.6139

NOTICE OF PRIVACY PRACTICES

English | Español

RELEASE OF INFORMATION

English | Español | Vietnamese

By submitting this form, you are consenting to receive marketing emails from: . You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

Gardner Family Health Network, Inc. doing business as Gardner Health Services, a 501(c)3 organization, receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. EIN: 94-1743078.

Board of Directors Application

Reference #1

Reference #2

Reference #3

Attach 3 Recommendation Letters

Experience:

GET IN TOUCH

Gardner Health Services Corporate Office 160 East Virginia Street, Suite 100 San Jose, California 95112

MEDICAL RECORDS

NOTICE OF PRIVACY PRACTICES

RELEASE OF INFORMATION

Subscribe