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Your Name*
Home Address*

If currently not employed, please describe past work or profession, attach resume if available
Work Address
Preferred Address for Correspondence

Please describe what interests, skills and leadership experiences (life, work, community) you could bring to LSCHC as a board member. Include any education, training, previous non-profit board experience or health care consumer perspective.
Are you a patient / client of LSCHC?
A patient / client is defined as a user of the Health Center clinical services who has received services within the past 2 years.
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This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.