ACH- 2018 ENRICH Health Equity Scholarship Application

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* 1. Personal Information

Name: *

Organization: *

Credentials (i.e. MD, RN, PA-C, PharmD, MSW, etc.) *

Address: *

City: *

State: *

Zip: *

Country: *

Email address: *

Job Title:

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* 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.

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* 3. Have you attended the ACH ENRICH Course before?

Yes

No

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* 4. Bio (200 words or less. Include past or current work you have done to address racism, diversity, health equity.)

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* 5. Why do you want to attend ENRICH?

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* 6. How will you contribute to the diversity of the course? (i.e. race, ethnicity, sexual orientation, gender identity, profession, etc.)

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* 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.

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* 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