Connecticut Association of Healthcare Executives
Women’s Forum
2017 ACHE CongressScholarship Award Application Form
Please complete all sections.
Date of Application:
Name:
Are you a member of CTAHE?
The CTAHE Women’s Forum will sponsor the scholarship awardee’s attendance at the American College of Healthcare Executives 2017 Congress on Healthcare Leadership, providing $1,500 towards reimbursement for the registration fee, and travel and lodging expenses.
If awarded the scholarship, I am able to cover any remaining conference expenses, beyond $1,500:
I.Personal Data:
Address:
Email:
Telephone:
II. Employment History: (complete this section and attach resume)
Current Employer
Employer:
Job Title:
Date Started:
Job Description:
Previous Employer # 1
Employer:
Job Title:
Date Started: Date Completed:
Job Description:
Previous Employer # 2
Employer:
Job Title:
Date Started: Date Completed:
Job Description:
Previous Employer # 3
Employer:
Job Title:
Date Started: Date Completed:
Job Description:
II.Academic Background:
School # 1
School attended:
Date Started: Degree Received/Will Receive:
Major/Concentration: GPA:
Completed degree?
School # 2
School attended:
Date Started: Degree Received/Will Receive:
Major/Concentration: GPA:
Completed degree?
School # 3
School attended:
Date Started: Degree Received/Will Receive:
Major/Concentration: GPA:
Completed degree?
IV.Leadership/Volunteer Work:(include professional, community, etc.)
Organization:
Dates of participation:
Description of involvement
Organization:
Dates of participation:
Description of involvement
Organization:
Dates of participation:
Description of involvement
Awards and Honors Received:
V.References: Please request letters of recommendation from two references, other than relatives, and indicate those individuals below:
Reference # 1
Name of person:
Title/role: Years known:
Name of Business/Organization:
Telephone number: Email address:
Brief description of relationship:
Reference # 2
Name of person:
Title/role: Years known:
Name of Business/Organization:
Telephone number: Email address:
Brief description of relationship:
VI.Career Goals and Objectives:
The purpose of this scholarship award is to recognize a deserving professional who demonstrates commitment to a career in healthcare management.Please respond to each of the following two questions in 200 to 500 words. Please attach the essays to the application.
Essay # 1: Why would you like to attend ACHE Congress? How will attending Congress enhance your career opportunities?
Essay # 2: Briefly describe your career aspirations.
VII. Application Submission and Signature:
By checking this box, I signify agreement with all procedures, rules, policies and any other processes used in the application and selection process. I certify that the information contained in this application is accurate and acknowledge understanding and agreement that selection of award recipients is within the complete and sole discretion ofthe CTAHE Women’s Forum Scholarship Committee.
Name of Applicant: Date:
Application Instructions
Please email your completed application to Kelly Foss (). The subject line of the email should be “CTAHE Women’s Forum Scholarship Application for YOUR NAME”.
The email should include the following attachments as Word or PDF files:
Application form
2 essays
Resume
Please ask your two references to email Kelly Foss with their recommendation letters. They can include the recommendation in the body of the email or as an attachment. The subject line of the email from the references should be “Recommendation of CTAHE Women’s Forum Scholarship Applicant: YOUR NAME”
Please email or telephone Kelly Foss at or 203-332-4948 if you have questions.
Scholarship applications must be received no later than February 6th, 2017.
Only completed applications will be considered.