Application to Community Healthcare Network's Scholars Program
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Applicant Information
Name
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Gender
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Address
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Telephone Number
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Format: (000) 000-0000.
Email
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How did you hear about us?
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Additional Information
for federal reporting purposes
Race
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Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
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Native Hawaiian or Pacific Islander
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Ethnicity
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Languages spoken
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Active or Retired Military Personnel
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No
Which branch?
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Disadvantaged background
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No
Are you an applicant who has (and whose spouse, if any, has) characteristics that indicate a higher likelihood of continuing to practice in a HPSA after the service obligation is completed, and who comes from a disadvantaged background? You must submit certification on the NHSC-approved form from your school that you: (i) were identified as having a “disadvantaged background” based on environmental and/or economic factors, or (ii) received a federal Exceptional Financial Need Scholarship.
Education/Certifications:
Please fill out at least one row.
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Rows
Institution
Dates
Area of Study
Degree
City/State
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3
Licenses:
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Rows
State
License Type
License Number
Issue Date
Expiration Date
1
2
3
Essay Questions
Please answer the questions below. Answer must be no more than 1 page.
Part of the goal of the CHN Fellowship is to address the healthcare disparities that face communities across the country. How do you foresee yourself helping to address these healthcare challenges?
While providing healthcare as a nurse practitioner is often a rewarding career, it is also a profession that entails addressing constant challenges. What do you see as the most significant issues the NP profession will face in the next 20 years, and what are some potential solutions for these problems?
Please upload essay submissions here (pdf, doc, docx).
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Required Documentation
CV in month/year format (include previous clinical rotations)
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Copy of State Issued ID
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