ACH- 2019 RCF 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:

I am currently a member of ACH.

I am NOT currently a member of ACH.

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* 3. RCF Pre-requisite:

I have attended an ACH ENRICH Course.

I have attended an ACH 1-day course facilitated by an ACH faculty member. If so, list date, location, and ACH faculty facilitator.

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* 4. Bio (200 words or less)

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* 5. CV Upload:

PDF, DOCX, DOC file types only.

Choose File

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* 6. Why do you want to be a Relationship-Centered Communication Facilitator?

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* 7. How will you contribute to the diversity of the RCF Program? (i.e. race, ethnicity, sexual orientation, gender identity, profession, geographic location, health population you serve, etc.)

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* 8. I have read and understand the scholarship awardee guidelines:

If selected as a scholarship awardee I will pay for my RCF program tuition ($2,950) in full, and will then be reimbursed the value of my scholarship ($2,000).

Yes

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* 1. Personal Information

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* 2. ACH membership status:

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* 3. RCF Pre-requisite:

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* 4. Bio (200 words or less)

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* 5. CV Upload:

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* 6. Why do you want to be a Relationship-Centered Communication Facilitator?

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* 7. How will you contribute to the diversity of the RCF Program? (i.e. race, ethnicity, sexual orientation, gender identity, profession, geographic location, health population you serve, etc.)

Question Title

* 8. I have read and understand the scholarship awardee guidelines:If selected as a scholarship awardee I will pay for my RCF program tuition ($2,950) in full, and will then be reimbursed the value of my scholarship ($2,000).

* 8. I have read and understand the scholarship awardee guidelines:

If selected as a scholarship awardee I will pay for my RCF program tuition ($2,950) in full, and will then be reimbursed the value of my scholarship ($2,000).