Connecticut Association of Healthcare Executives Women’s Forum
2019 ACHE Congress Scholarship Award Application Form

Please complete all sections.

Date of Application:
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Name:
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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 2019 Congress on Healthcare Leadership, providing $1,500.00 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 am applying for the $1,500.00 student scholarship and a paid membership to CTAHE:
I. Personal Data:
Address:
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Email:
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Telephone:
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II. Employment History: (complete this section and attach resume)
Current Employer
Employer:
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Job Title:
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Date Started:
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Job Description:
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Previous Employer # 2
Employer
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Job Title
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Date Started:
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Date Completed:
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Job Description:
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Previous Employer # 3
Employer
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Job Title
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Date Started:
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Date Completed:
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Job Description:
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III. Academic Background:
School # 1:
School Attended
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Date Started:
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Degree Received/Will Receive
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Major Concentration / GPA
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Completed Degree:
School # 2:
School Attended
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Date Started
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Degree Received/Will Receive
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Major Concentration and GPA
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Completed Degree:
School # 3:
School Attended
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Date Started
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Degree Received/Will Receive
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Major Concentration / GPA
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Completed Degree:
IV. Leadership/Volunteer Work:(include CT AHE, professional, community, etc.)
1. CT AHE: _______________________________________
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Dates of Participation: (from/to)
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Description of Involvement:
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2. Organization
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Dates of Participation: (from/to)
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Description of Involvement:
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3. Organization
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Dates of Participation: (from/to)
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Description of Involvement:
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4. Organization
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Dates of Participation: (from/to)
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Description of Involvement:
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Awards and Honors Received
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V. References: Please request letters of recommendations from two references, other than relatives and indicate those individuals below:
Reference # 1
Name:
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Title/Role: Years Known
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Name of Business/Organization:
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Telephone Number:
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Email Address:
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Brief description of relationship:
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Reference # 2
Name:
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Title/Role: Years Known
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Name of Business/Organization:
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Telephone Number:
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Email Address
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Brief description of relationship:
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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?" OR, If applying for the student scholarship "How would the award of this scholarship and membership to CTAHE be beneficial?
Essay # 2: Briefly describe your career aspirations. All applicants should complete this essay.
VII. Application Submission and Signature:
By checking the box below, 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 of the CTAHE Women’s Forum Scholarship Committee.Name of Applicant:
Application Instructions:
Please email your completed application to Julie Vigil (vigil@uchc.edu). 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 Julie Vigil (vigil@uchc.edu) 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”For Questions: Please contact Julie Vigil @ vigil@uchc.edu or 860-463-6404
Scholarship applications must be received no later than Tuesday, January 15, 2019.
Only completed applications will be considered.
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