Queensway Carleton Hospital - Board of Directors Application Form 2026

Board of Directors Application Form

*Full Name:

Chosen Name (if different than legal name):

Pronouns:

*Street:

Unit/Apt.:

*City:

*Province:

*Postal Code:

*Mobile Phone:

ext.

*Email:

*Why are you interested in serving as a Board Member at QCH?:

*Other current volunteer or community involvement:

Area(s) of expertise/contributions you feel you can make to QCH as a Board Member. Choose all that applyHealth Systems
Human Resources and Organizational Effectiveness
Risk Management
Quality/Safety Leadership
Social & Community Services and Population Health
System Integration / Collaborative Development

QCH is committed to a merit-based selection process that promotes equity, ensures fairness, includes equity-deserving groups, and reflects the diversity of the communities we serve. The following questions are voluntary and designed to gather basic information to identify your membership in an equity-deserving group. Your voluntary response to these self-declaration questions is used exclusively for statistical purposes, with a focus on promoting equity, diversity, inclusion, and representation in the appointment process. All provided information is confidential and will not be disclosed or used for personal identification. Please respond to only those questions you are comfortable with.

Consent for the Collection of Self-IdentificationOption 1: I am not a member of an Equity-Deserving Group.
Option 2: I do not wish to complete the Self-Identification Declaration Form (please scroll to the end of the form and click the 'submit' button to complete your application).
Option 3: I wish to complete the Self-Identification Declaration Form.

You may self-declare as belonging to multiple Equity-Deserving / Employment Equity groups. You can self-declare membership in both Indigenous Peoples and Racialized Communities groups.
Our Board of Directors Recruitment and Selection Equity Initiative aims to ensure fair representation for equity-deserving groups, including women, Indigenous peoples (First Nations, Métis, Inuit, as well as urban Indigenous peoples), those with disabilities, racialized communities, trans individuals, and 2SLGBTQI+ members. We strive to eliminate bias in Board member selection processes, address past discrimination, and create a diverse and inclusive Board of Directors that mirrors our community's diversity.

Do you identify as a Woman? Women are members of a designated group under the Employment Equity ActYes
No

Do you identify as part of 2SLGBTQI+ Communities? 2SLGTBQI+ is an acronym for Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer and/or Questioning, Intersex, and the plus reflects the countless affirmative ways in which people choose to self-identifyYes
No

Do you identify as an Indigenous Person? An Indigenous person is a member of a First Nation, Métis, Inuit, or urban-residing Indigenous peoples, and Indigenous peoples with mixed Ancestry. Indigenous people, Aboriginal people, or members of a First Nation include status, treaty, or registered Indians, as well as non-status and non-registered IndiansYes
No

If you wish to provide further details, please specify the group(s) to which you belong:

Are you a member of a racialized group? A person in a racialized group in Canada is someone (other than an Indigenous person as defined above) who is non-Caucasian in race or non-white in colour, regardless of place of birth, including individuals of mixed raceYes
No

If you wish to provide further details, please select the box(es) that best describes your originBlack
Chinese
Filipino
Japanese
Korean
Non-White Latin American (including: Indigenous persons from Central and South America, etc.)
Non-White West Asian
North African or Arab (including: Egyptian; Libyan; Lebanese; Iranian; etc.)
South Asian/East Indian (including: Indian from India; Bangladeshi; Pakistani; East Indian from Guyana, Trinidad, East Africa; etc.)
Southeast Asian (including: Burmese; Cambodian; Laotian; Thai; Vietnamese; etc.)
Person of Mixed Origin (with one parent in one of the racialized groups)

Or, please specify:

Are you a Person with a DisabilityYes
No

If you wish to provide further details, please select the box(es) that apply to youHearing-related disabilities (e.g., Deafness, significant hearing loss, etc.)
Vision-related disabilities (e.g., Blindness or significant visual impairment, etc.)
Mobility-related disabilities (e.g., Use of mobility aids, difficulty walking, etc.)
Cognitive or mental health related disabilities (e.g., Intellectual disability, memory-related impairment, cognitive or mental health condition, etc.)
Communication-related disabilities (e.g., Use of augmented or alternative communication methods, difficulty speaking or being understood, etc.)
Chronic pain or illness-related disabilities (e.g., fibromyalgia, arthritis, diabetes, asthma, epilepsy, etc.)
Other disabilities not listed above.

If you have other disabilities not listed above, please specify (optional):

*Upload 2-page maximum resume (PDF preferred):

*Upload 500-word cover letter (PDF preferred):

Welcome to Queensway Carleton Hospital Website

Board of Directors Application Form 2026

Apply now to be a QCH Board Member!

Board of Directors Application Form

We are processing your submission.
Please do not press back or refresh.

Welcome to Queensway Carleton Hospital Website

Board of Directors Application Form 2026

Apply now to be a QCH Board Member!

Board of Directors Application Form

We are processing your submission.Please do not press back or refresh.

We are processing your submission.
Please do not press back or refresh.