ACH- 2019 FIT 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. FIT Pre-requisite:

I have successfully completed the ACH RCF Program (Relationship-centered Communication Facilitators).

I have graduated from the ACH Train-the-Trainer program and have attended an ACH ENRICH course.

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* 4. Bio (200 words or less)

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* 5. Why do you want to participate in the ACH Faculty-in-Training Program?

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

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

If selected as a scholarship awardee I will pay for my FIT program tuition ($1,250) in full, and will then be reimbursed the value of my scholarship ($1,250).

Yes

No