ACH- 2020 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 ($69-$210) will go toward a 2020 ACH membership, and the remaining funds will be used toward ENRICH registration).

I am currently a member of ACH.

I am NOT currently a member of ACH.

Preference will be given to those from racial and ethnic groups that are under-represented in the health professions. These may include, but are not limited to: Hispanic/Latinx, Black/African-American, Asian-American, Native American / Alaska Native, Native Hawaiian / Pacific Islander, and people from outside the U.S. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/diversityushealthoccupations.pdf

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* 3. Based on the information above, are you from a racial or ethnic group that is considered under-represented in the health profession?

Yes

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

Yes

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

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* 6. Why do you want to attend ENRICH?

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

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* 8. Please share specific examples of how you plan to apply the knowledge and skills you develop at ENRICH to the promotion of health equity.

Please read the scholarship awardee guidelines if selected as a 2019 recipient:

Scholarship Award Guidelines:
1. If not a member of ACH, part of the awarded scholarship funds will go toward a 2020 ACH membership ($69-$235), and the remaining funds will be used toward ENRICH registration.
2. Recipients must register by the early bird deadline: April 23, 2020

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

Question Title

* 1. Personal Information

Question Title

* 2. ACH membership status (If not a member of ACH, part of the awarded scholarship funds ($69-$210) will go toward a 2020 ACH membership, and the remaining funds will be used toward ENRICH registration).

Question Title

* 3. Based on the information above, are you from a racial or ethnic group that is considered under-represented in the health profession?

Question Title

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

Question Title

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

Question Title

* 6. Why do you want to attend ENRICH?

Question Title

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

Question Title

* 8. 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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* 9. I have read and understand the scholarship awardee guidelines if selected as a 2020 recipient:Name:

* 9. I have read and understand the scholarship awardee guidelines if selected as a 2020 recipient:

Name: