ACH- 2018 ENRICH Health Equity Scholarship Application Question Title * 1. Personal Information Name: * Organization: * Credentials (i.e. MD, RN, PA-C, PharmD, MSW, etc.) * Address: * City: * State: * Zip: * Country: * Email address: * Job Title: Question Title * 2. ACH membership status (If not a member of ACH, part of the awarded scholarship funds will go toward a 1-year membership, and the remaining funds will be used toward ENRICH). I am currently a member of ACH. I am NOT currently a member of ACH. Question Title * 3. Have you attended the ACH ENRICH Course before? Yes No Question Title * 4. Bio (200 words or less. Include past or current work you have done to address racism, diversity, health equity.) Question Title * 5. Why do you want to attend ENRICH? Question Title * 6. How will you contribute to the diversity of the course? (i.e. race, ethnicity, sexual orientation, gender identity, profession, etc.) Question Title * 7. Please share specific examples of how you plan to apply the knowledge and skills you develop at ENRICH to the promotion of health equity. Question Title * 8. I have read and understand the scholarship awardee guidelines if selected as a 2018 recipient:Scholarship funds will be awarded in the form of reimbursement.Within 30 days of the conclusion of the course, I will submit copies of receipts for my course registration or applicable travel expenses for reimbursement (flight, ground transportation, parking, lodging, and/or meals) up to the maximum scholarship award of $1,000. Yes No Done