Fellows Exit and Contact Update Form

Name*

First NameLast Name

In what program did you participate?*

Department with which you served*

What is the best email to contact you at in the future (please use a non-CH email)*

Phone Number #1 - please provide a non-Church Health phone number*

Area CodePhone Number

Alternative Phone Number

Area CodePhone Number

Address at which you can be reached - if possible, provide a permanent address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Do you know what you are doing after you Scholar year?

YesNo

If you have plans for after your Scholar year, select the category that best describes your plans.

What profession will you be taking up/ pursuing?*

Where will you be going to study/ work? *

Organization name

City

State

Please provide a short statement describing your experience with Church Health. i.e. How has the organization impacted you and your future? How do you believe the program prepared you for your next steps?

Is there a particular instance that stands out - something that you will always remember - with a doctor, a patient, other Scholars, other staff members, or community member that served as a "defining moment" for you here at Church Health (please omit specific details, such as names or PHI pieces)?

Do you give your consent for Church Health to use any portion or all of your above statements for promotional purposes?*

YesYes-anonymouslyNo

Fellows Exit and Contact Update 2017-2018