Healthcare CIO Boot Camp Scholarship Application Form - Healthcare IT

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)

CHIME Member's Name (sponsoring member)*

First Last

CHIME CIO Sponsoring Member email*

I would qualify for scholarships available to the following populations:

Please check all that apply.

Women
Minority
Military
Critical Access or Community Hospital

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

Yes
No

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

How many years of HIT Leadership experience do you have?*

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?

I commit that I have arranged funding for, or will be able to cover, all additional travel expenses not covered by this Full Registration Scholarship necessary to utilize the scholarship if awarded.

Yes
No

Provide any additional comments on the questions above here:

Supporting Documents

Upload Current Resume*

Candidates should provide a current resume highlighting their experience and/or achievements in the healthcare IT field.

Accepted file types: docx, doc, pdf, jpg, gif, png, pub, dot, Max. file size: 32 MB.

Upload Letter of Recommendation (required for non-CHIME members only)

Accepted file types: pdf, Max. file size: 32 MB.

Please use .pdf