Board Application

Disability Rights NC’s Nominating Committee and CEO review board member applications and screen prospective board members. Our by-laws contain specific requirements related to the number of members from four regions of the state. Members of the DRNC Board must collectively reflect the diversity of the state in terms of disability, racial/ethnicity, age and point of view (primary and secondary consumers of service).

Please call DRNC at (919) 856-2195 if you need assistance filling out this form, or would like it in another format. We will keep the application on file for one year.

Application for Board of Directors

Contact information

First name(Required)

Last name(Required)

Street address(Required)

City(Required)

Zip code(Required)

Phone number(s)(Required)

Email address(Required)

Business/Organization (if applicable)

Demographics

DRNC is required to have a Board with a majority of members who are individuals with a disability or a family member of a person with a disability. DRNC also seeks a diverse board that reflects the race, ethnic, socioeconomic, geographic, gender, age and disability diversity of NC. Personal information requested on this application is only used for ensuring the diverse board composition DRNC needs to fulfill its mission.

1. What is your relationship with disability? Check all categories that apply to you:(Required)

Person with a disability

Family member of a person with a disability

Other

If other, please describe:(Required)

What is the disability?(Required)

Please check all that apply.

Intellectual / Developmental

Mental Health

Physical

Sensory

Traumatic Brain Injury

2. Race

White

Black/African American

Hispanic/Latino

Asian/Pacific Islander

American Indian

Two or more races (please specify below)

Please describe:(Required)

3. Ethnicity(Required)

Hispanic/Latino

Not Hispanic/Latino

4. Are you an NC resident?(Required)

Yes

What is your county?(Required)

5. Age range(Required)

18-24

25-40

41-60

Over 60

6. Gender identity(Required)

Male

Female

Other

Decline to state

If other, please describe(Required)

Background and experience

7. How did you hear about DRNC?(Required)

8. Why do you want to join the DRNC Board of Directors?(Required)

9. Please describe your education and experiences related to disability, advocacy, leadership, and/or nonprofit organizations.(Required)

10. Describe an experience in which you advocated for yourself or someone with a disability.(Required)

11. List current or previous board or advisory council experience, including any leadership roles:(Required)

12. What skills, training, resources, and expertise will you bring to the DRNC Board?(Required)

Please select all that apply.

Advocacy/Public policy

Entrepreneurship

Financial management

Fundraising

Government

Human resources

Legal

Marketing/Public relations

Networking (identify communities below)

Strategic planning

Technology

Other

*Networking communities(Required)

If other, please describe.(Required)

13. Are you able to commit to a 3-year board term, attending 4 board meetings per year (potentially in various NC locations), and to participating on a board committee?(Required)

Yes

Reference

Please provide contact information for someone whom you have worked in an advocacy, volunteer, or professional role.

Reference name:(Required)

Reference phone:(Required)

Email(Required)

Street address:(Required)

City, State and Zip code(Required)

Please enter the city, state and zip of your reference.

Consent

I agree to the following: If selected to serve on the Board of Directors of Disability Rights North Carolina, I agree to participate in the training and orientation program for all Board members. I also agree to participate in quarterly meetings of the Board, which may involve travel around the state of NC. (Due to COVID-19, all meetings are currently being held virtually.) I understand that if I am unable to attend official DRNC meetings on a regular basis, I may be replaced as outlined in the DRNC Bylaws. I also understand that I will be expected to participate on at least one board committee and complete other assignments as needed. DRNC will reimburse travel costs consistent with DRNC policies. I have provided a full disclosure consistent with the DRNC conflict of interest policy (below).

Applicant signature(Required)

Date submitted:(Required)

Conflict of Interest Disclosure Statement

Consistent with policies established by the Board of Directors of DRNC, I hereby certify that the following is a true and complete disclosure of my relationships, if any, to businesses, agencies, organizations, or other groups which have the potential of creating an actual or apparent conflict for me in carrying out my responsibilities as a member of the DRNC Board.

1. I am (or a member of my immediate family is) an employee, officer, or director of an agency(ies), business(es), or organization(s) which is primarily related to providing a service to persons with disabilities.(Required)

Yes

2. I am (or a member of my immediate family is) an employee, officer or director, or have an ownership interest of 10% or more, in any of the following: for profit business; another nonprofit organization; or governmental agency which provides some type of service to persons with disabilities. This can be either a paid or volunteer relationship.(Required)

Yes

3. I am (or a member of my immediate family is) an employee, officer, director, or a person with a significant (makes decisions about the business) ownership interest in any other the types of businesses, organizations, agencies, or groups providing any type of service that might create the appearance of or potential for a conflict of interest.(Required)

Yes

4. If you have answered YES in any of the questions above, please provide a brief explanation of the potential conflict:(Required)

Board Application

Application for Board of Directors

Contact information

Demographics

Background and experience

Reference

Consent

Conflict of Interest Disclosure Statement

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