Application for Appointment to Board of Director of Boone County Family Resources

Boone County Family Resources was established in 1976 with the passage of a special property tax levy. The agency, through its Board of Directors, purchases and provides services for eligible persons of all ages with developmental disabilities. As an administrative agent of the Department of Mental Health, the scope of services has expanded since establishment of the agency, and has grown to include residential services, vocational and practical living skills training, and family support services. The agency is nationally accredited and has a multi-million dollar budget. Additional information about the agency may be obtained at the agency's website, www.bcfr.org , or by contacting the agency.

Composition of the board of directors must meet the statutory requirements of the enabling legislation. Additionally, persons appointed to the board must comply with the provisions of the bylaws of the board, agency policy and the resolution adopted by the Board regarding disclosure of potential conflicts of interest on file with the Missouri Ethics Commission. Board members of Boone County Family Resources also serve on the board of Life and Work Connections, Inc., a Section 501(c)(3) corporation that provides vocational services to young adults through a contractual arrangement with Boone County Family Resources. As appointees of a statutorily created entity with broad powers, board members have certain fiduciary duties, which require that they conduct themselves without conflict to the interest of the agency they serve. Conflicts of interest are not prohibited, but disclosure is critical. Disclosure should not be construed as creating a presumption of impropriety or as automatically precluding someone from participation. Rather, it reflects the recognition of the many factors that can influence one's judgment and a desire to make as much information as possible available to other participants. Potentially conflicting interests may relate to programs and services or operations, such as contracts with third parties.

To apply for the Boone County Family Resources Board, please complete the following online application or complete and print the PDF form available below. Be sure to sign and date the printed copy before submitting. Applications may be delivered to the Boone County Commission Office in person; sent by mail to 801 E. Walnut Street, Room 333; or emailed as an attachment to commission@boonecountymo.org .

Download PDF Application

ONLINE APPLICATION
*APP IDAUTOSEQ**
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NAME OF COMMISSION BOARD	Boone County Family Resources Board of Directors
Name:
Home Address:
City:		Zip:
Employment Address:
City:		Zip:
At which address would you prefer to be contacted:	HOME WORK
Email Address (where you wish to be contacted):
Home Phone:		Business Phone:
Cell Phone:

Section 205.970 RSMo requires that at least 7 of the board members be residents of the county where the facility is located.
Are you a Boone County resident?	YES NO
How long have you lived in Boone County?	Years:	Months:

Are you a registered voter?	YES NO
Have you previously served as a member of a board? If yes, identify the board and the dates of service.
What other professional, civic or community endeavors are you currently involved in?
Are you or have you previously held any local, state or federal government positions, appointments or elected office(s)? If so, please list dates and positions held.

Section 205.970, Revised Statutes of Missouri, requires that at two of the nine members of the board of directors be related by blood or marriage within the third degree to a handicapped person as defined in Section 205.968 as a person who is “lower range educable or upper range trainable mentally retarded or a person who has a developmental disability.” [Relationships in the third degree include mother, father, child, brother, sister, (including half, step and in-law relationships in these same categories), and grandparent, grandchild, aunt, uncle, niece, nephew, great grandparent, great grandchild.]
Are you related by blood or marriage within the third degree to a handicapped person as defined in Missouri statutes? If yes, please identify the person and the relationship.	YES NO
Person:
Relationship:

For purposes of the following questions, “related family member” is defined to include relationships within the third degree by blood or marriage. [Relationships in the third degree include mother, father, child, brother, sister, (including half, step and in-law relationships in these same categories), and grandparent, grandchild, aunt, uncle, niece, nephew, great grandparent, great grandchild.]
Have you or a related family member applied for eligibility and been determined eligible or ineligible for services of Boone County Family Resources at any time?	YES NO
If yes, identify the individual who applied, their relationship to you and the date of application.

Explain briefly why you are seeking this position and identify any special qualifications you have for this position.

Do you or any related family member have any financial interest, directly or indirectly, in any contract or subcontract with Boone County Family Resources; or have you or a related family member been employed by any agency or entity that contracts or subcontracts with Boone County Family Resources; or in the sale to Boone County Family Resources of land, materials, supplies, or services?	YES NO
If yes, please explain.

Are you or any related family member now or have you or a related family member ever been employed by Boone County Family Resources?	YES NO
If yes, please give dates of employment and position held.

Do you or does any related family member have any other interest which might conflict or be perceived to conflict with your duty of loyalty to the interests of Boone County Family Resources?	YES NO
If yes, identify the interest and the relationship.


Have you ever been arrested, charged, or convicted of any felony?	YES NO
If yes, please explain.

Have you ever been disciplined, cited, or sanctioned for a breach of ethics or unprofessional conduct by, or been the subject of a complaint to any court, administrative agency, professional association, disciplinary committee, or other professional group?	YES NO
If yes, please explain.

Are your Boone County taxes paid in full to date?	YES NO
If no, please explain.

References:	(Include name, nature of relationship, contact information, and number of years known)

By my submission, I agree to comply fully with board policy, bylaws, and conflict of interest requirements of the board of directors and certify that the information above is complete and accurate to the best of my knowledge and that should a potential conflict arise during my term, I will bring it to the attention of the Board of Directors of Boone County Family Resources.