BOARD STANDING COMMITTEE
COMMUNITY REPRESENTATIVE
CANDIDATE FORM
Muskoka Algonquin Healthcare is currently looking for individuals from the community, who due to the relevance
of their expertise in a particular area, and interest in making a volunteer commitment to MAHC, could make a
valuable contribution to the work of the Board as a non-director committee member.
If you are interested in serving as a Board Committee Community Representative, we ask that you complete and
submit the following form along with a resume.
CANDIDATE INFORMATION
Name:
Mailing address:
City/Town:
Postal Code:
Phone (Home):
Phone (Mobile):
E-Mail Address:
Present Occupation:
EXPERIENCE & SKILLS: Please check all that apply.
 Accounting/Financial
 Government
 Politics/Lobbying
 Business
 Health Care
 Public Relations
 Strategic Planning
 Human Resources
 Public Speaking
 Training/Education
 Community Services
 Entrepreneur
 Legal
 Social Services
 Facilities Management
 Biomedical Ethics
 Management
 Other (please explain):
 Information Technology
 Other Board(s)
BOARD COMMITTEES: Please indicate the Board Committee that you would be interested in serving.
 Quality & Patient Safety
 Governance
 Strategic Planning
 Resources
Please explain why you wish to be considered for a position on the MAHC Board of Directors (attach additional pages if
required)
QUALIFICATIONS & STATEMENT OF COMMITMENT
I, the undersigned, hereby apply to be considered for as a Board Committee Community Representative, and in doing so,
acknowledge and declare that: (please check each statement below to indicate your acknowledgement)
 I can regularly commit to 3-5 hours bi-monthly to prepare for and attend Committee meetings. (Meeting schedules vary and are
provided in advance)
 I could, with notice, attend additional meetings when required.
 I will be committed to furthering the Mission, Vision and Values of Muskoka Algonquin Healthcare.
 I understand that if chosen to proceed through the interview process a Police Criminal Record Check will be required and any
nomination will be contingent on the completion of this process.
 I will act honestly, in good faith and in the best interests of the Hospital and in so doing, support the Hospital in fulfilling its
mission and discharging its accountabilities.
 I will offer constructive contributions to Committee discussions.
 Respect the views of other members of the Committee and the role of the Chair.
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Signature
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Date
Should you have any questions or concerns regarding this candidate form please feel free to contact the
Board Liaison @ 705.789.0022 x 2342 or via e-mail @ tammy.tkachuk@mahc.ca.
Further information about Muskoka Algonquin Healthcare and the Board of Directors can also be accessed
by visiting www.mahc.ca.
Please return candidate form along with a current resume to:
Muskoka Algonquin Healthcare
Nominations Committee
c/o Board Liaison Office
100 Frank Miller Drive
Huntsville, ON P1H 1H7
ADMINISTRATIVE USE ONLY:
Date form received:
Approval date: