Fellowship Application Fellowship Application First name Last name Current professional position Institution Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Contact Email Number of years as EACH member (a minimum of 6 does not have to be consecutive) Biographical statement Please include any relevant achievements in relation to healthcare communication. (Maximum of 250 words) Word count: Contribution to EACH rEACH Years in post (eg 2016 – 2021) tEACH Years in post (eg 2016 – 2021) pEACH Years in post (eg 2016 – 2021) Advisory Committee Years in post (eg 2016 – 2021) Special Interest Group Years in post (eg 2016 – 2021) Executive Committee Member Years in post (eg 2016 – 2021) EACH periodic committee membership/participation Below please indicate the years of your involvement/participation on any of the following committees. ICCH planning committee Years (eg year of conference) Forum planning committee Years (eg year of conference) ICCH/Forum abstract reviewer Years (eg year of conference) Summer School Years (eg year of conference) Senior in Pairing with Colleagues initiative Years (eg year of conference) Member of Expert Jury for EACH Awards Poster Research Teaching Other Poster Years (eg year of conference) Research Years (eg year of conference) Teaching Award Years (eg year of conference) Description of your contributions to EACH projects, products and dissemination activities: Please describe your contributions to EACH projects, products and dissemination activities – use as much space as needed. (Note – some of these contributions may be in your capacity as a standing EACH committee member). To add the series of questions for an additional activity (up to a maximum of five), please click the toggle on, after the detailed description field. Activity 1 Name/description of project, product, activity and your role in it (Maximum of 300 words) Word Count: Which committee if applicable, was this activity related to? Dates of contribution Who would be best to comment on your involvement in this activity? eg sub-committee, chair, project lead etc. (Please include their email address.) To complete the questions in respect of a second activity, please click to toggle on. Toggle 2 Activity 2 Name/description of project, product, activity and your role in it (Maximum of 300 words) Word count: Which committee if applicable, was this activity related to? Dates of contribution Who would be best to comment on your involvement in this activity? eg sub-committee, chair, project lead etc. (Please include their email address.) To complete the questions in respect of a third activity, please click to toggle on. Toggle 3 Activity 3 Name/description of project, product, activity and your role in it (Maximum of 300 words) Word Count: Which committee if applicable, was this activity related to? Dates of contribution Who would be best to comment on your involvement in this activity? eg sub-committee, chair, project lead etc. (Please include their email address.) To complete the questions in respect of a fourth activity, please click to toggle on. Toggle 4 Activity 4 Name/description of project, product, activity and your role in it (Maximum of 300 words) Word Count: Which committee if applicable, was this activity related to? Dates of contribution Who would be best to comment on your involvement in this activity? eg sub-committee, chair, project lead etc. (Please include their email address.) To complete the questions in respect of a fifth activity, please click to toggle on. Toggle 5 Activity 5 Name/description of project, product, activity and your role in it (Maximum of 300 words) Word count: Which committee if applicable, was this activity related to? Dates of contribution Who would be best to comment on your involvement in this activity? eg sub-committee, chair, project lead etc. (Please include their email address.) Candidate Letter of Application Please upload a word document or pdf of a 1 page single spaced application letter briefly describing the reasons why you should qualify for the Fellowship and highlighting your most substantive contributions to EACH. You should include in your letter any contributions you have made which progress the EACH aims. Please include the following: Number of years as a member of EACH. Descriptions of substantive contributions to EACH in narrative form. Who in EACH can attest to your contributions (committee chairs, co chairs etc) who can provide this upon request of the fellowship committee. Please provide name and contact details. Drop a file here or click to upload Choose File Maximum upload size: 2MB Additional comments Additional comments (if needed) (Maximum of 300 words) Word count I hereby declare that all the information contained in this application is true and correct, and if successfully awarded EACH Fellowship, I guarantee will maintain ethical and professional standards and not bring the Association into disrepute. If you are human, leave this field blank. Submit
