10 Miss. Code. R. 402-2.8
Charter School Board Member Questionnaire
(To be completed individually by each proposed board member for the Charter School)
The purposes of this survey are: 1) to supply pertinent information to the application review team; 2) to encourage board members to reflect individually as well as collectively on their common mission, purposes, and obligations at the earliest stage of school development; and 3) to identify any potential conflict of interest you may have as a board member.
Conflict of Interest
The information requested below is being requested to identify any potential conflicts of interest that you may have as a board member. This is in alignment with best practices in non-profit and charter school governance and is also DPS policy for its board members. If the charter school is approved, any conflict of interest that is identified must be addressed by the charter school in alignment with its board conflict of interest policy.
Background/Criminal History Checks
Background checks are an important volunteer management tool for charter schools. The safety of students, employees, and board members is of upmost importance. Moreover, the judicious oversight of the school's finances and operations is among the governing board's main responsibilities. Accordingly, applicant is to submit criminal background checks on all Charter School Board Members.
Contact Information
Please check each area of expertise you would contribute to the board:
| Community Service | Education | Finance Fundraising | Law |
| Management | Marketing | Parental Personnel Involvement | Public Relations |
If yes, please describe.
School Mission and Program:
Governance:
Certification
I recognize that all information submitted with this conflict of interest disclosure (with the exception of the background check) becomes a matter of public record, subject by law to disclosure upon request to members of the general public. I will hold the Mississippi Charter School Authorizer Board, its trustees, officers, employees or authorized agents harmless from liability for the disclosure of any information it reasonably believes is true based upon my representations.
I hereby certify that the information contained in this document is true and complete to the best of my knowledge and, if the proposed charter school is approved, agree to notify the chair of the board at the charter school at which I will serve of any change that may create a conflict of interest. Further, if the proposed charter school is approved, I recognize that falsification or failure to submit a complete annual conflict of disclosure becomes justification for removal.
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Board Member's Signature Date
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Board Member's Typed Name Date
10 Miss. Code. R. 402-2.8