Palomar Health Fellowship Application Form

Instructions: Please provide the following information in the spaces provided below.

Last Name: ______First Name: ______

Phone Number: ______E-mail Address: ______

Address: ______

City: ______State: ______Zip Code: ______

Education:

List all colleges and universities attended (undergraduate/graduate) and please send corresponding official graduate transcript(s).

Institution Name: ______

City: ______State: ______

Degree/Major: ______Graduation Year: ______GPA: ______

Institution Name: ______

City: ______State: ______

Degree/Major: ______Graduation Year: ______GPA: ______

Institution Name: ______

City: ______State: ______

Degree/Major: ______Graduation Year: ______GPA: ______

By the start of the Fellowship will you have received your graduate degree? ☐ Yes ☐ No

Please indicate which of the following degree(s) you are currently pursuing or have completed:

☐ MS ☐MHA ☐ MPH ☐ MBA ☐ PhD ☐ Other: ______

Is your master’s program accredited through the Council on Education for Public Health (CEPH), Association to Advance Collegiate Schools of Business (AACSB), and/or Commission on Accreditation of Healthcare Management Education (CAHME)? ☐ Yes ☐ No


Recommendations:

Please list the two individuals and their contact number that will be providing recommendation letters. One professional and one academic reference are required.

Name / Title / Phone Number / Email Address
1.
2.

How did you hear about our Fellowship Program? (Please indicate all that apply):

☐ American College of Health Care Executives Website ☐ Graduate School/Career Center ☐ Palomar Health Website

☐ Word of Mouth ☐ Other: ______

Please check three (3) areas of healthcare leadership you are most interested in:

Palomar Health Fellowship Application Form

  Ambulatory Care

  Compliance

  Facilities Planning

  Finance

  Foundation

  Human Resources

  Information Systems

  Marketing

  Operations

  Physician Relations

  Quality

  Strategic Planning

  Other:

______

Palomar Health Fellowship Application Form

Statement of Intent (2 paged, double-spaced, 11-pt font):

In your statement, please discuss: 1) your decision to pursue an administrative fellowship and how it will help you achieve your future career goals 2) why you are interested in Palomar Health 3) the specific skills you would bring to the fellowship 4) how you will prepare for the fellowship.

Application Materials:

All items below should be received in one envelope by October 2, 2017.

☐ Application Form

☐ Current Resume

☐ Statement of Intent

☐ Official graduate school transcript

☐ 2 signed and sealed letters of recommendation (1 professional, 1 academic)