PEAK Parent Center

Prospective Board/Committee Member Information Form

PEAK Parent Center is committed to involving individuals

with diverse skills, backgrounds, and experiences and from
diverse geographic areas on its Board of Directors and on
committees of the Board. If you are open to being considered
for such a role, we would appreciate your completing this
form.

I. Personal Information Date: ______________________________

Name:__________________________________________________________________________

Title/Organization or Business:_______________________________________________________

Address
(Home):_______________________City:__________________________State/Zip:____________

Address
(Work):_______________________City:__________________________State/Zip:_____________

Telephone/Day:____________________ Telephone/Evening:_________________________

Fax:__________________________ E-mail:_________________________________________

Please explain any personal connection you may have with disability issues: If you are a parent of
a child with a disability, please give the child’s age and disability label.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

II. Information to Help Us Know You

Professional skills:_______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
 Interests:________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Community service:_______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Affiliations with civic groups, corporations, or foundations:__________________________________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Educational background:____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Experience with governance of non-profit organizations:___________________________________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Personal experience with any ethnic or cultural groups:____________________________________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Anything else you’d like to share with us:________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

III. Involvement with PEAK Parent Center

Please describe your connection to PEAK?_____________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Share with us what interest you have about our organization:_______________________________

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

What can you contribute to PEAK? ___________________________________________________

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Please return this form to:

BARBARA BUSWELL
PEAK Parent Center
611 North Weber, Suite 200
Colorado Springs, CO 80903