Apprenticeship Program

Apprenticeship Program Application

EOPH Assembly Apprenticeship Program Application

First Name *
Last Name *
Current Institution *
Current Position *
Academic Title (if appropriate)
Year of training, or years since completion of specialty/research training (i.e., for clinical fellows/trainees, year of fellowship; for faculty, years since critical care fellowship; for PhDs, years since completion of post-doc) *
Address *
Address 2
City *
State *
Zip *
Phone *
Email *
Research/Career Mentor (if no mentor, please write "none") *
Mentor's Institution (if no mentor, please write "none") *
How would you identify your Gender (optional)
Male
Female
How would you identify your race and/or ethnicity (optional)
I am applying for *
Program Committee
Planning Committee
Either
Discipline (check all that apply) *
Physician
Nurse
Pharmacist
Nurse Practitioner
Physician Assistant
Physical Therapist
Occupational Therapist
Dietician
Respiratory Therapist
Social Worker
Researcher
Other:
If other, please specify:
At prior ATS International Conferences, I have (check all that apply) *
Presented a poster (includes case reports and abstracts)
Presented an Oral Abstract
Presented at a Scientific Symposium
Presented at a Sunrise/Post-graduate seminar
Facilitated a poster session
Moderated a poster-discussion session
Chaired/Co-chaired a Scientific Symposium
Other
If other, please specify:
Please briefly explain your ability to commit to 2 years of service on the committee, timely assignment completion, and attendance at conference calls and in-person meetings? *
Please describe your career interests and goals (250 words, maximum) *
How do you foresee participation in the EOPH Assembly Early Career Professional's Working Group Apprenticeship Program facilitating achievement of your career goals described above (250 words, maximum)? *
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Last Reviewed: October 2018