Fellowship Application Fellowship Application First name Last name Current professional position Institution Pays AfghanistanAland IslandsAlbaniaAlgeriaSamoa américainesAndorreAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustralieL'AutricheAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiqueBelizeBéninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrésilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodgeCameroonCanadaCape VerdeÎles CaïmansCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatieCubaCuracaoCyprusCzech RepublicDanemarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaÉrythréeEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaAllemagneGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIslandeIndeIndonesiaL'IranIrakIrlandeIsle of ManIsraëlItalieJamaïqueJaponJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLibériaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaisieMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauriceMayotteMexiqueMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMarocMozambiqueMyanmarNamibieNauruNepalPays-BasNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorvègeOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandle PortugalPuerto RicoQatarReunionRoumanieRussieRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovaquieSloveniaSolomon IslandsSomaliaAfrique du SudSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanEspagneSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSuèdeSuisseSyriaTaïwanTajikistanTanzanieThaïlandeTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluOugandaUkraineUnited Arab EmiratesRoyaume-UniÉtats-UnisUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambieZimbabwe Email du contact 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 atteindre Years in post (eg 2016 – 2021) enseigner Years in post (eg 2016 – 2021) pêche Years in post (eg 2016 – 2021) Comité consultatif Years in post (eg 2016 – 2021) Special Interest Group 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) Summer school planning committee/facilitator Years (eg year of conference) ICCH/Forum abstract reviewer Years (eg year of conference) Senior in Pairing with Colleagues initiative Years (eg year of conference) Member of Expert Jury for EACH Awards Poster Recherche Enseignement Other (please describe)Other (please describe) Poster Years (eg year of conference) Recherche 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. Déposez un fichier ici ou cliquez pour télécharger Choisir le fichier Taille maximale du fichier : 2MB Additional comments Additional comments (if needed) (Maximum of 300 words) Word count If awarded, are you happy to have your name included on the EACH Fellowship webpage? * Oui Non 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. Si vous êtes un humain, ne remplissez pas ce champ. Soumettre
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