Board policy manual & workplace conduct - Kingston General Hospital

SUBJECT:Policy # V-A-1Director and Non-Director DeclarationPage 2 of 2As a Director, I agree to comply with the performance expectations as stated in Article 4 of theKGH Bylaw. In addition, I confirm that I have read and understand and/or will comply with thespecific provisions as outlined in Article 4.06 “Conflict of Interest”, Article 4.07 “Confidentiality”,Article 4.08 “Principles of Governance and Board Accountability”, Article 4.09 “Roles of theBoard”, Article 4.10 “Responsibilities of the Board”, and Article 4.11 “Roles and Responsibilitiesof Individual Elected and Ex-officio Directors”.As a non-Director serving on a Board Committee, I have read and understand the performanceexpectations as stated in Article 4 of the KGH Bylaw as it pertains to Directors. I understandthat I am also expected to comply with certain provisions as it pertains to my role as a non-Director.As a Director/non-Director, I confirm that I do not have a conflict of interest which would preventme from serving as a Director of the Board pursuant to Conflict of Interest Guidelines developedby the Board as appended.I hereby consent to act as a Director/Non-Director of Kingston General Hospital. I also herebyconsent pursuant to the provisions of the By-Law of Kingston General Hospital to the holding ofmeetings of the Board of Directors or of any Committee of the Board of Directors by means ofsuch telephone, electronic or other communication facilities as permit all persons participating inthe meeting to communicate with each other simultaneously and instantaneously. Theseconsents will continue in effect from year to year so long as I am a Director/Non-Director of theBoard.I agree to abide by the confidentiality provisions in the hospital by-law and hospital privacypolicies.I undertake to advise the Hospital in writing of any change of address as soon as possible aftersuch change.Dated:______________________________________Signature:______________________________________Print Name:______________________________________Address:__________________________________________________________________________________________________________________