Community Health Fellows Program Application

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Name*

First Last

Please select your preferred pronouns.*

He/Him

She/Her

They/Them/Theirs

Other

Gender*

Date of Birth*

How did you hear about this program?*

The CCALAC Community Health Fellows Program is scheduled to end in June 30, 2026. Are you available to serve as a Fellow until 6/30/2026?*

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone Number*

Email Address*

Enter Email Confirm Email

Do you speak and/or write in any languages other than English?*

Yes

Please list the languages and level (Basic, Proficient, Fluent)*

Are you moving within the next 3-6 months?*

Yes

Education (Check the highest level of education that you will have completed by the start of the program.)*

High school diploma

Some college

Associates degree

Bachelor’s degree

Graduate degree

Other

List the school for which you completed or will complete your highest level of education.*

Location (City, State)*

Major (Area of Study)*

Degree type (HS Diploma, AA,BA, BS, MPH)*

Date Degree Earned or Expected*

Motivational Statement*

We would like to understand more about you and your reasons for applying to the CCALAC Community Health Fellows Program. Take a few minutes and consider the experiences which have made you the person you are today and describe how it sparked your interest in community health.

Community Service*

Describe your most recent involvement in community service. Explain why you decided to serve or get involved, and what you learned or how it made you feel. (Ensure this experience is listed on your resume as well)

Healthcare Experience*

Describe your experience working with medically underserved areas and/or medically underserved populations (low-income, homeless, etc.). Why do you wish you to serve in a program that works in these areas and with these populations?

Emergency Management Experience*

Tell us about your experience or interest, if any, in Emergency Management.

At the end of this application you have need to upload a Resume and OPTIONAL Cover Letter. Please ensure that both are updated and accurately reflect your education, internships/fellowships, part-time/full-time work experience, extracurricular activities and any volunteer experiences.

Select the skill areas below in which you have experience and/or training and indicate how you gained those skills. If you do not have any, please write N/A. Example: took courses in college, helped family with their patient portal, was a peer counselor, etc.

Healthcare (including community and public health)*

Electronic Health Records Systems and/or Patient Portal*

Health Education:*

Behavioral Health:*

Case Management/Counseling:*

Community Outreach:*

Please complete the information below for 2 references that we can contact. Select people who you know well and who are familiar with your personal background, education, employment, and/or professional skills. You should not ask a family member or friend to serve as a reference. Consider asking work supervisors, professors, counselors, coaches, peers, classmates, co-workers, or someone else familiar with your motivation and community involvement.

Reference 1 Name*

First Last

How long have you known them:*

In what capacity do you know them: (Co-worker, supervisor, professor, etc.):*

Best Phone Number to reach them at:*

Email Address:*

Enter Email Confirm Email

Reference 2 Name*

First Last

How long have you known them:*

In what capacity do you know them: (Co-worker, supervisor, professor, etc.):*

Best Phone Number to reach them at:*

Email Address:*

Enter Email Confirm Email

Have you ever been convicted as an adult, or adjudicated as a juvenile offender, of any criminal offense by either a civilian or military court, other than a minor traffic violation?*

Yes

If yes, please explain:*

Upload Your Resume*

Accepted file types: pdf, Max. file size: 32 MB.

Please submit your resume as a PDF

Signature

2026-2027 Community Health Fellows Program Application