Scholarship Application & Agreement

Scholarship Application and Agreement:

Advancing Health Literacy Franklin County (AHLFC) is pleased to offer the Institute for Healthcare Advancement (IHA) Health Literacy Specialist Certificate Program to partners committed to increasing organizational health literacy. Please complete this application to receive a unique code for one or multiple no cost licenses to the certificate program.
Please select the option below that applies to you:

Employee of a Franklin County, Ohio based organizationEmployee of an organization, outside of Franklin County, Ohio, that serves Franklin County, Ohio residentsIndependently contributing to advancing Health Literacy in Franklin County, OhioNone
Name of your Organization:*
Type of Organization:

Public HealthHealthcare DeliveryCommunity-Based OrganizationFaith-Based OrganizationFederally Qualified Health CenterSocial Service AgencyOther
Name:*

First NameLast Name
Email:*
Phone Number:*

Area CodePhone Number
Job Title:*
Applicant is applying on behalf of:

Individual/self (one)An organization requesting multiple licenses
Please select the number of licenses you are requesting:
To optimize this valuable opportunity, we ask scholarship recipients to agree to participate in the activities below that are designed to increase health literacy in Franklin County. Please check the boxes to indicate that each individual receiving a certificate scholarship agreess to the following:

Start the program within 30 days of activationComplete all 7 micro-credentials of the Certificate within 90 days of activationParticipate in brief surveys to help us track our grant progress, growth, and reachProvide a testimonial and/or engage with the AdvancingHL.org websiteEngage in one or more health literacy opportunities that are offered at no cost by AHLFC (Listed at the end of this form)
Please tell us about your organization. Please include information about your organization's mission, vision, and current focuses:*
Please list the hard-to-reach communities your organization serves: (Examples: Individuals experiencing homelessness or housing instability, Individuals with disabilities, Immigrants, Refugees, New Americans, Somali, Nepali, etc.):*
Please tell us how you see the information learned in this program enhancing your role, benefitting your organization, and/or increasing organizational health literacy at your organization:*

Advancing Health Literacy Franklin County, Health Literacy Opportunities:

	Currently Participating	Interested & Would Like More Information	N/A
Advancing Health Literacy Franklin County, Partner Advisory Committee
Columbus Public Health, Health Literacy Committee
EnLiven organizational health literacy assessment(s)
Health Literacy Learning Collaborative
Health Literacy Training (Digital Health Literacy, CLAS, Health Literacy Introduction, In-depth Health Literacy Training)

Please list any questions or notes you have for us:
This opportunity is supported by the Office of Minority Health (OMH) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $3,990,000 with 100 percent funded by OMH/OASH/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by OMH/OASH/HHS, or the U.S. Government. For more information, please visit www.minorityhealth.hhs.gov
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Scholarship Application and Agreement: