CARE HEALTH LEADERSHIP APPLICATION

Email
example@example.com
Phone Number
Please enter a valid phone number.
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you live in Bridgeport, Waterbury, Ansonia, Derby, Stamford or the Naugatuck Valley?

YesNo
If Yes, how long have you lived there?
If accepted, attendance is required at all sessions. Will you be able to attend bi-weekly sessions?

Yes, I will attendNo, I will not be able to attend

Why do you aspire to participate in the Community Research Fellowship program?
Please discuss how your past experiences and current knowledge make you uniquely qualified to serve as a Community Research Fellow.
Please explain how serving as a Community Research Fellow aligns with your personal or professional goals.
If you could achieve ONE health goal in your neighborhood or in the New Haven community, what would it be?

If selected, are you willing to work in a group setting to accomplish a collaborative community health project?

YesNo
How did you hear about the CARE Research Fellows Program?

Recommended by a friend or colleagueSocial MediaFlyerEmailNeighborhood MeetingCommunity OrganizationOther
References Please provide 2 references that can comment on your potential as a Community Research Fellow. Your references should be able to speak about your previous community engagement and/or your passion for gaining leadership in this area.
Please provide a reference that can attest to your ability to work in a community setting.

First NameLast Name
Relationship to you
Their Phone Number
Please enter a valid phone number.
Their Email
example@example.com
Please provide a second reference that can attest to your ability to work in a community setting.

First NameLast Name
Relationship to you
Their Phone Number
Please enter a valid phone number.
Their Email
example@example.com

Please verify that you are human*
I have read and understood the terms of the program and stipend eligibility.

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COMMUNITY RESEARCH FELLOW APPLICATION