2027 Civitas Networks for Health® Board of Directors Nomination Form

Thank you for your interest in serving on the Civitas Networks for Health® Board of Directors. Please complete the information below by 5:00 p.m. ET on July 17, 2026, to be considered for the slate of candidates. Additional information on the selection, timeline, and process can be found in the FAQs.

Please contact Michaela Cohoon (mcohoon@civitasforhealth.org) with any questions.

Nominee Information

Applicant Name

Applicant Job Title

Applicant Email

Name of Applicant's Executive Assistant

Email of Applicant's Executive Assistant

Please describe why you are interested in serving on the Civitas Board of Directors (100 word max):

Please explain the value you would bring to the Civitas Board of Directors (200 word max):

Please describe any prior experience serving as a voting member on a Board of Directors or similar governing body:

The Civitas Board is diverse in terms of individual experience and expertise, cultural background, gender/orientation, geography and size of organizations represented. Additionally, the Board encompasses a mix of strategic, innovative, and pragmatic thinkers to support short and longer-term organizational and industry goals.

Please share how you believe your participation on the Board will enhance the representation of diverse perspectives and experiences?

Please indicate any industry groups, professional associations, or formal networks you currently participate in (or have participated in the past 5 years):

If you are not the CEO/Executive Director of your organization, please indicate the name of the CEO/Executive Director who has endorsed your nomination.

If you are not the CEO/Executive Director, please provide a letter of recommendation from your CEO/Executive Director. If you are the CEO/Executive Director a letter of recommendation from your Board of Directors or industry colleagues is optional but welcomed.

The following questions are optional and will be used to better understand the demographics of the Board.

Organizational Information

Please complete the following section with information about your organization.

Organization Name

Please describe your organization’s service area in terms of region(s), state(s), or counties as concisely as possible.

If you selected other, please describe:

Please share any other information you believe would be helpful to the Civitas Nominating Committee and staff when reviewing your nomination.

Contact Information