ACH- 2018 ENRICH Scholarship Application Question Title * 1. Personal Information Name: * Organization: * Credentials (i.e. MD, RN, PA-C, PharmD, etc.) * Address: * City: * State: * Zip: * Country: * Email address: * Job Title: Question Title * 2. Bio (200 words or less): Question Title * 3. All scholarship applicants must be a CURRENT member of ACH to apply. I am currently a member of ACH. I am NOT currently a member of ACH. Question Title * 4. Statement of Interest: (e.g Why would you like to attend ENRICH?) Question Title * 5. Have you attended an ENRICH Course before? Yes No Question Title * 6. How will you contribute to the diversity of the course? (i.e. Profession, perspective, race, ethnicity, etc.) Question Title * 7. How do you plan to use/share the skills you learn at your organization/home institution? Question Title * 8. I have read and understand the scholarship awardee requirements if selected as a 2018 recipient: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 course2. A summary of their ENRICH experience and how it will affect their workThree 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 Yes No Question Title * 9. Enter any additional comments in the space below. Done