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Vot-ER Civic Health Fellowship Interest Form

The 2024 Civic Health Fellowship application period has closed. To be alerted when our next application period opens, please complete the interest form below.

First Name

*

Last Name

*

Suffix

Email

*

Organization Name

*

Please use your organization's full name, without abbreviations

Organization Type

*

If your organization type is not listed, select "Other"

Does your organization primarily serve patients who identify as any of the following? (Check all that apply)

*

Does your organization primarily serve patients who identify as any of the following? (Check all that apply)

24 years old or younger.

Medicaid/CHIP eligible or do not have health insurance.

Self-identified as Black/African American.

Self-identified as Hispanic/Latino/e.

Self-identified as Native American/Alaskan Native.

Individuals with physical/mental/emotional disabilities.

Individuals in rural communities.

Best served in a language other than English.

I am not in a patient-facing role/organization.

None of the above apply.

State

*

Zip Code

*

Occupation

*

If your occupation is not listed, select "Other"

Phone Number

Untitled checkboxes field

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