RRCC Patient Board Interest Form

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Thank you for your interest in joining the Rock River Community Clinic Board of Directors as a patient representative. Please complete the requested information below and an RRCC team member will be in touch regarding any board vacancies.

Thank you!
RRCC Team

Your Name: *

Email Address: *

Phone Number: *

Which clinic(s) do you currently visit to receive RRCC healthcare services? *

Whitewater medical clinic

Watertown medical clinic

Fort Atkinson dental clinic

Required

What city do you reside in? *

If currently employed, what city do you work in? *

Why are you interested in serving on the RRCC Board of Directors as a patient representative? *

How did you hear about this opportunity? *

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