2019 Cohort IRHA Fellows Application Question Title * 1. First Name: OK Question Title * 2. Last Name: OK Question Title * 3. Major/Program: OK Question Title * 4. Organization/University: OK Question Title * 5. Home Address Line 1: OK Question Title * 6. Address Line 2: OK Question Title * 7. City: OK Question Title * 8. State: OK Question Title * 9. Zip Code: OK Question Title * 10. Home County of Residence: OK Question Title * 11. Phone Number: OK Question Title * 12. Email Address: OK Question Title * 13. How did you learn about the Indiana Rural Health Association Fellows Program? (Check all that apply): IRHA Fellow Alumni IRHA Board Member IRHA Conference On-Campus Meeting IRHA Website Other -please indicate: OK Question Title * 14. My areas of interest are (Check all that apply): Business and Administration Government Agency and Legal Regulations Rural Education and Research Rural Primary Care or Specialty Clinical Practice Population Health Mental Health and Addictions/Social Services Nonprofit Health IT Telehealth Public Health Other -please indicate: OK Question Title * 15. In an effort to make your experience more fulfilling, please indicate a topic/field of interest that you would like to focus your research project on (i.e.: rural economic development): OK Question Title * 16. Are you currently a member of the IRHA? Yes No OK Question Title * 17. I understand that if accepted to the Indiana Rural Health Association Fellows Program, I must be a member of the Indiana Rural Health Association or be willing to join before the start of the program. Membership must last for the duration of the program. Yes No OK Question Title * 18. I understand that if accepted to the Indiana Rural Health Association Fellows Program, I must cover my driving expenses to two meetings in Indianapolis and one meeting in French Lick, IN. Lodging, event registration, and meals will be provided by the Indiana Rural Health Association. Yes No OK Question Title * 19. Please attach a personal statement of 500 words or less that describes your particular interests and issues in rural health. How might your participation in the Policy Fellows Program enable you to address these issues? * PDF, DOCX, DOC file types only. Choose File Choose File No file chosen Remove File Please attach a personal statement of 500 words or less that describes your particular interests and issues in rural health. How might your participation in the Policy Fellows Program enable you to address these issues? * OK Question Title * 20. Please attach a curriculum vitae/resume.* PDF, DOCX, DOC file types only. Choose File Choose File No file chosen Remove File Please attach a curriculum vitae/resume.* OK DONE