From Theory to Taking Action: Addressing Racism in MedicineApplication 2022Applications are due by January 14, 2022. If you have any questions, please contact Chrissie Connors at cconnors@challiance.org Name * First Name Last Name Email * Demographic Information Gender * Woman Man Trans Woman Trans Man Genderqueer, non-binary, non-confirming or gender fluid I prefer not to say Another identity If you answered "another identity," you can share your identity below Pronouns * Leave blank if you prefer not to answer She / Her / Hers He / Him / His They / Them / Their I do not use any of the listed pronouns I prefer not to say If you do not use any of the listed pronouns, you can let us know your pronouns below Race / Ethnicity * Leave blank if you prefer not to answer American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White I do not identify as any of the above I prefer not to say If you do not identify as any of the above, and wish to tell us what you identify as, you can do so below Hispanic or Latino? * Leave blank if you prefer not to answer Yes No i prefer not to say Professional Background Name of Employer * Please avoid using abbreviations City or Town and State where you work * Please use the state abbreviation Describe your primary role at your institution * Clinician Educator Researcher Administrator Other Job Title / Roles * Year of Graduation from Clinical Training * Medical Specialty * Commitments I can commit to paying the full tuition of $1,000 by the February 1, 2022 deadline through self-funding, CME funding, or institutional support. * We have a limited number of partial scholarships. Please note below if you are requesting financial support and if so, how much you are able to pay for tuition. Yes, I can commit to paying the full tuition by the deadline No, I cannot commit to paying the full tuition by the deadline I would like financial support If you cannot commit to paying the tuition by the deadline, or are requesting financial support, please explain below I can commit to attending all sessions for this course, and completing all pre-reading assignments prior to the session. * Expectation of 1-2 hours of preparatory work per session. All sessions take place 1-4pm EST on Wednesday on the following dates: March 23 April 6 April 20 May 4 May 18 Yes No Unsure Anti-Racism Experience What is your background in learning about and/or addressing racism in medicine? (250-500 words) * Why are you applying to this course? (250-500 words) * What change do you hope to achieve in addressing racism at your institution? Please describe the project you would like to workshop with faculty and peers in this course (less than 500 words) * Would you like to be added to our e-mail list to learn of future courses and events? * Yes No How did you hear about this course * Thank you for Submitting your application. Notice of acceptance to the course will be sent on January 28. If you have any questions, please email Chrissie at cconnors@challiance.org
