CHIME23 Fall Forum Scholarship Application

Candidate's Name*

First Last

Job Title*

Organization*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

I am a:*

CHIME Member
Member of AEHIA, AEHIS or AEHIT
Employee of a CHIME member team (Must enter sponsor name and email below for eligibility)
Other (please explain in additional committee comment box)

Sponsoring Member's Name*

First Last

Sponsoring Member's Email*

I would qualify for scholarships available to the following populations:

Please check all that apply

Minorities
Women
Military
Critical Access Hospital

As an employee of a rural hospital or health system I would qualify to receive a Neal Patterson Community and Rural Hospital Scholarship*

Eligibility: Current CHIME members and employee of a community or rural hospital or health system

Yes
No

Briefly explain your interest in attending the program and your need for a scholarship.*

Have you applied for a CHIME scholarship before?

Yes
No

Which scholarship and when?

Have you received a CHIME scholarship before?

Yes
No

Which scholarship and when?

What activities/committees have you been involved in with CHIME

Additional comments for committee considerations:

Upload Supporting Documents

2. Upload Current Resume*

Please use .pdf

Accepted file types: pdf, Max. file size: 1 GB.

* CHIME may request to share/publish the submitted essay for educational/marketing purposes. No information shall be shared without the express written consent of the scholarship applicant.

Neal L. Patterson Community and Rural Hospital Scholarship

APPLICATION CRITERIA

Qualifications

Materials Required

Upload Supporting Documents