PRC Community Board Application

PRC Community Board Application

Thank you for your interest in serving on the Pediatric Resource Center Community Board of Directors. Please complete the application below.  

If you have any questions, please call Carole at 309-624-9594 for assistance.

If you prefer, you may print and mail the form to Carole Siefken at Pediatric Resource Center, 530 NE Glen Oak Ave., Peoria, IL 61637, or fax the form to Carole at (309) 624-9694.

 

Thank you for your interest in serving on the Pediatric Resource Center Community Board of Directors. Please complete the application below.  

If you have any questions, please call Carole at 309-624-9594 for assistance.

If you prefer, you may print and mail the form to Carole Siefken at Pediatric Resource Center, 530 NE Glen Oak Ave., Peoria, IL 61637, or fax the form to Carole at (309) 624-9694.

 

 

 

 

 

 

 

 

 

 

 

14. Preferred Method of Contact:

14. Preferred Method of Contact:

required15. Preferred Phone:

required15. Preferred Phone:

required16. Preferred Email:

required16. Preferred Email:

required17. Preferred Mailing Address:

required17. Preferred Mailing Address:

 

required22. Skills, experiences and interests:

required22. Skills, experiences and interests: