ACH- 2019 FIT Scholarship Application Question Title * 1. Personal Information Name: * Organization: * Credentials (i.e. MD, RN, PA-C, PharmD, MSW, etc.) * Address: * City: * State: * Zip: * Country: * Email address: * Job Title: Question Title * 2. ACH membership status: I am currently a member of ACH. I am NOT currently a member of ACH. Question Title * 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. Question Title * 4. Bio (200 words or less) Question Title * 5. Why do you want to participate in the ACH Faculty-in-Training Program? Question Title * 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.) Question Title * 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 Done