Apply 2020 - Nashville Health Care Council Fellows

Personal Information
Name
Prefix First Last Suffix
Nickname/Familiar name for Name Badge:*
Your Preferred Initials (i.e., JWR):*
Your Preferred Name for Media Releases (i.e., Jane Smith):*
Home Address*
Street Address Address Line 2 City State ZIP Code Country
Mobile Phone*
Your Primary Email*

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Professional Information
Position/Title*
Company/Organization*
Parent Company (if applicable)
Business Address*
Street Address Address Line 2 City State ZIP Code Country
Business Phone*
Assistant Name
First Last
Assistant Email
Assistant Phone
Assistant Title
Number of Direct Reports*
Job Title of Person to Whom You Report

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General Information
Preferred Mailing Address*
- Business Address
- Home Address
Years with Current Employer*
Which function best describes your position? (Select one only)*
Please describe your position
Is your company a member of the Nashville Health Care Council?*
- Yes
- No
- Not sure
Are you a full-time practicing clinician?*
- Yes
- No
Is your organization considered a government entity?*
- Yes
- No
Provide a brief description of your organization and/or business unit. (1500 characters max)*
Briefly describe your current responsibilities: (2000 characters max)*
Write a short bio about yourself: (2000 characters max)*

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Personal Goals
What do you hope to gain by participating in Fellows?*
Please identify a single challenge, issue or problem you feel is critical to solve to transform the health care industry.*

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Industry and Leadership Background
Please list any recent or current community and board leadership positions.*
Participation Requirements
Fellows 2020 Session Dates
- Opening Retreat: Thursday & Friday, January 23-24
- Day 1: Friday, February 7
- Day 2: Friday, February 21
- Day 3: Friday, March 6
- Day 4: Friday, March 27
- Day 5: Friday, April 10
- Day 6: Friday, April 24
- Closing Retreat: Thursday & Friday, May 14-15
Will you be able to fulfill the commitment of attending the opening retreat, seven Fellows classes and closing retreat?*
- Yes
- No
Do you have the support of your employer for the time required to participate in this program?*
- Yes
- No
Please upload your resume*
Accepted file types: pdf, doc, docx.
References

Below, please enter the information for two references. After submitting this application, your references will receive a link to our reference form page where they will fill out a letter of recommendation for you. Only after receiving these letters of recommendation will your application be considered complete.

Alternatively, you can send them to this page to fill out the reference form.
First Reference Name*
First Last
First Reference Title*
First Reference Company*
First Reference Email*
First Reference Phone*
Second Reference Name*
First Last
Second Reference Title*
Second Reference Company*
Second Reference Email*
Second Reference Phone*
Billing Information

Payment for Fellows tuition is due upon acceptance into the program and must be received by the Nashville Health Care Council no later than Friday, January 10, 2020. Lack of payment might impact your participation in the Council Fellows program, which begins January 23, 2020. The Fellows Advisory Committee will select the 2020 class and you will be notified of your application status no later than Friday, December 6, 2019.
Comments
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Apply for the Class of 2020

Step 1 of 5

Personal Information

Professional Information

General Information

Personal Goals

Industry and Leadership Background

Participation Requirements

Fellows 2020 Session Dates

References

Billing Information