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.

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?

Which scholarship and when?

Have you received a CHIME scholarship before?

Which scholarship and when?

What activities/committees have you been involved in with CHIME?

Additional comments for committee considerations:

Supporting Documents

Upload Current Resume*

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

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

Please use .pdf