SCHOLARSHIP APPLICATION

Thank you for your interest in the Creating Safer Healthcare Course.

Please fill out the Scholarship Application below and
we will be in touch soon.

Thank you!

NAME

First Name

Last Name

PRONOUNS

PHONE

Please include country code

Country

(###)

###

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Tell me a little about who you are and what your work is.

What inspires you to do what you do in the world?

How might CSH be supportive to your mission?

Is there anything else I should know about you?

Is there anything that makes you nervous about joining CSH?

What else do you have going on in your life that might make it difficult to complete all the modules?

What is the one thing you’re most excited about in CSH?