Board of Director Application Form | Quinte Health Care
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Quinte Health Care
Exceptional Care, Inspired by You.

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Board of Director Application Form

Deadline for applications is March 21, 2017 4:00 p.m. EST.  Applications received after this time will not be accepted.

Our Mission
We are an integrated system of four hospitals working with our partners to provide exceptional care to the people of our communities.

Our Vision
Exceptional Care, Inspired by You.

Our Values
Imagine it’s you (Compassion)
Respect everyone (Respect)
Take ownership (Accountability)
We all help provide care (Teamwork)
Always strive to improve (Learning)

Selected applicants will be invited to an informal education session with a board and staff member prior to their interview at Belleville General Hospital.  Tentative dates for the informal sessions are April 11 & 12 between 11:00 a.m. - 4:00 p.m. and April 17, 2017 from 9:00 a.m. - 1:00 p.m.  Each candidate’s session will be approximately 60 min in length. 

Board interviews will be held on April 25 & 26, 2017 between 8:00 a.m. – 4:00 p.m. at Belleville General Hospital.  You will be notified by April 6, 2017 if you have been selected for an interview.

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Qualifications. I, the undersigned, hereby apply to be considered for election as a Director of QHC, and in doing so, acknowledge and declare that:
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I am at least eighteen (18) years of age.
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I do not have an undischarged bankruptcy.
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I recognize that board terms are for three years and that barring unforeseen circumstances I am committing to complete the term.
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I am not in a Conflict of Interest (Board Policy V-A-13). The full policy may be reviewed upon request.
A conflict of interest arises in any situation where a Director's duty to act solely in the best interests of the corporation and to adhere to his or her fiduciary duties is compromised or impeded by any other interest, relationship or duty of the Director. A conflict of interest also includes circumstances where the Director's duties to the corporation are in conflict with other duties owed by the Director such that the Director is not able to fully discharge the fiduciary duties owed to the corporation.
Below I disclose my participation or affiliation with any organizations that may create an actual or perceived conflict of interest with QHC:
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Within the past two years, I have not been an employee or member of the professional staff of QHC or an employee of a Foundation or Auxiliary supporting one of the QHC hospitals.
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I am not a family member of an employee or member of the professional staff of QHC or an employee of a Foundation or Auxiliary supporting one of the QHC hospitals.
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I am not an appointed member of a Board for a Foundation supporting one of the QHC hospitals.
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I am not an appointed member of a Board or an Executive for an Auxiliary supporting one of the QHC hospitals.
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Within the past two years I have not held an elected office in any city, town, municipality or county council or other local government wholly or partially within the areas serviced by the hospital.

Review of Director's Responsibilities
If I am appointed as a Director of the QHC, I:
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will support the mission, vision and core values of QHC;
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will advise QHC if there is a circumstance that would cause me to automatically vacate the office of Director;
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will abide by the conflict of interest and confidentiality provisions governing Directors;
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will sign the Director's Declaration;
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have read and understood the Guidelines for the Selection of Directors and the Responsibilities as an Elected and Ex-Officio Director;
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will exercise my powers and discharge my duties as Director as required by law;
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understand that I will not be compensated for my services as a Director (as required by charitable law), although I may be reimbursed for approved out-of-pocket expenses incurred for meetings and educational events in relation to the performance of my duties as a director; and.
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understand that I will be required to submit evidence of a satisfactory Criminal Reference Check.

Profile
I understand that QHC wants to ensure that its Board of Directors has the necessary skills and experience to govern QHC. To assist QHC in establishing a Board that meets these objectives, I am providing the information requested below:
Please check the top three key strengths (ranking them with one being the top strength) which apply to you along with a statement regarding the acquisition of this experience.
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Resume: A copy of a current resume or a brief biographical sketch (for example, a half page about your work and community experiences) must accompany your application along with a covering letter outlining your qualifications, experience and the reasons you wish to serve. Please include the names and contact information of two references (who are not related to you) for your application to be considered.
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File Upload Validation Code

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File Upload Validation Code

If you are recommended for appointment as a Director, you will also be required to obtain a satisfactory Criminal Reference Check.

DECLARATION: If my application is approved (please see Guidelines for the Selection of Directors), I agree to act as a Director of QHC and, in my capacity as a Director of QHC, I shall at all times act honestly and in good faith. I acknowledge that Directors of QHC must act in the best interest of QHC as a whole and not solely in the interest of the community in which they reside. As a Director of QHC I agree that I shall abide by QHC's By-Laws and policies and all governing legislation. I fully understand that any errors in my application may result in my application for consideration as a Director being refused or my Directorship being revoked. I undertake to advise QHC immediately in writing of any change in the information contained in this Application.
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Acceptance of declaration

Deadline: March 21, 2017 4:00 pm EST Applications received after this time will not be considered.
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  Validation Code