ACH- 2018 ENRICH Scholarship Application

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* 1. Personal Information

Name: *

Organization: *

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

Address: *

City: *

State: *

Zip: *

Country: *

Email address: *

Job Title:

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* 2. Bio (200 words or less):

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* 3. All scholarship applicants must be a CURRENT member of ACH to apply.

I am currently a member of ACH.

I am NOT currently a member of ACH.

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* 4. Statement of Interest: (e.g Why would you like to attend ENRICH?)

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* 5. Have you attended an ENRICH Course before?

Yes

No

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* 6. How will you contribute to the diversity of the course? (i.e. Profession, perspective, race, ethnicity, etc.)

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* 7. How do you plan to use/share the skills you learn at your organization/home institution?

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* 8. I have read and understand the scholarship awardee requirements if selected as a 2018 recipient:

Scholarship Winner Post-Course Requirements:
One week after the course, scholarship recipients must submit:
1. Three goals related to new skills they learned at the course
2. A summary of their ENRICH experience and how it will affect their work

Three months after the course, scholarship recipients must submit:
3. A reflection describing how they've applied their skill goals and what outcomes they observed/experienced

Yes

No

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* 9. Enter any additional comments in the space below.