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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

Email

Organization Name

Please use your organization's full name, without abbreviations

Organization Type

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

The majority of my patients are (select 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.

Self-identified as Native American/Alaskan Native.

Best served in a language other than English.

None of the above apply.

I am not in a patient-facing role.

My institution views itself as a space that is designed to serve (select all that apply):

LGBTQ+ communities.

Rural communities.

Indigenous communities.

Individuals with physical/mental/emotional disabilities.

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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