Health Equity Scholars Program Application Please fill out the below application form if you would like to be considered for the 2024 Health Equity Scholars Program. If you have any questions about the program or application, please email Alanna Kate Cruz, Program Manager at alcruz@challiance.org. Name * First Name Last Name Email * Name of Employer: * Year of Graduation from Clinical Program * Please Indicate your Health Profession * Social Worker Therapist Speech Pathologist Registered Nurse Physician Nurse Practitioner Physician Assistant Other If you indicated "other", please specify How many years have you been working in this health professions role? * Please indicate your degrees and the years they were completed: * What State do you work in? * AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY What town/city do you work in? * What type of organization do you work with? * Select All that apply For-profit hospital Non-Profit Hospital Academic Teaching Hospital Community health center/Clinic Community Based Organization Correctional Facility Self-Employed Other, please specify If you indicated "other", please specify Describe the populations you serve as a clinician and health equity advocate * e.g. LGBTQ, BIPOC, incarcerated, Medicaid insured Pronouns She / Her / Hers He / Him / His They / Them If you use pronouns that are not listed and would like to let us know what they are, please do so below I Identify my gender as: Man Woman Genderqueer/nonbinary I Prefer not to disclose If you do not identify with any of the above genders and would like to tell us how you identify, please do so below. I Identify my sexual orientation as: Asexual Bisexual Gay Straight (Heterosexual) Pansexual Queer I prefer not to disclose If you do not identify as any of the above sexual orientations and would like to tell us how you identify, please do so below: Race and Ethnicity Asian Black / African American Native Hawaiian or Other Pacific Islander White American Indian / Alaskan Native I prefer not to answer If you don not identify as any of the above and would like to tell us how you identify, please do so below: Hispanic or Latino? * Yes No I prefer not to answer If there is anything else you would like to share about your identities, please do so below About You What inspired you to apply for the health equity scholars program? What do you hope to gain from this program? Please include any relevant health equity/advocacy work you have participated in and/or are passionate about. (Approximately 500 words) * * Advocacy project All Health Equity Scholars are required to submit a description of a specific advocacy action/project. The project should be an ongoing or potential project that relates to health equity. Scholars will be selected based on a demonstrated commitment to health equity and the potential to lead advocacy activities in the future. My project is about: * Anti-Racism & Health Climate Health LGBTQ Health Immigrant Health Other Please describe the health equity project you would like to design and implement within your institution or your community. In your response, address how this project will address key health equity issues and the community/patient/staff populations this project will seek to support. (Approximately 500 words) * * Tell us few things about your project. Do you have a team within your institution/community that is working with you on this project? * Yes No If yes, how many team members do you have on your team? Based on the information that you currently have, how likely is that your institution will support this project and your health equity work? 1 - not likely at all 2 3 4 5 - full support and buy in On a scale of 1-5, how would you rate the current commitment of your institution towards health equity? 1 2 3 4 5 The tuition for the Health Equity Scholars Program is $3,750. Our expectation is that institutions will sponsor scholars to participate in this program for their enrichment and for the project that will be developed to support the institution. Please provide us with your status: * I am working to secure institutional support, but unable to currently confirm that I am able to pay the tuition I have secured institutional support for participation in the course, or will use other means (ie CME funds) to pay the tuition Other If yes, please provide the name of your supervisor If you answered "other", please elaborate below Time Commitment The scholars will be expected to: • Develop and lead an advocacy project within their organization/community Attend Online Launch Workshop (January), Immersion (June) & Final Gathering (October) • Participate in the online curriculum, that includes monthly online two-hour sessions • Project Coaching Sessions (approx. 1 hour/month) • If attending in person is possible, in-person attendance of final gathering. ** Please find the detailed 2024 Program Schedule on the main HES page. Are you able to dedicate the time outlined above to this course? * Yes No Unsure If you answered unsure, please describe If other, please describe. Thank you for your application. If you have any questions in the interim, please contact Alanna Kate Cruz at alcruz@challiance.org
