[ninja_form id=3] AIHM Fellowship Application Duplicate for ZBrains Part 1: Contact Information ELIGIBILITY: The AIHM Fellowship in Integrative Health & Medicine is designed for licensed clinicians who have completed a master's degree or higher. We are currently accepting medical physicians, osteopathic physicians, podiatrists, naturopathic physicians, chiropractic physicians, dentists, advanced practice registered nurses, physician assistants, licensed acupuncturists, registered dietitians, pharmacists, occupational therapists, physical therapists, licensed clinical social workers, and psychologists. Other health care professionals may apply for consideration. Or, you may submit your CV for a preview to fellowship@aihm.org INSTRUCTIONS: Required documents that you will need to upload in this application (please use .jpg, .doc or .pdf files) are below. Please use the naming convention: Document_LastName_MonthYear you are applying to join. For example, Donna Brown would save her documents like this: CV_Brown_Oct2021; Diploma_Brown_Oct2021 Curriculum Vitae (CV) / Resume* - Your CV should be current and relevant education, organizational memberships, faculty or teaching positions, published articles or books, research and work/practice experience. Headshot - Your current photo Professional School Diploma* that is US Department of Education recognized or its foreign equivalent (such as MD, ND, PA, NP, DC, LAc, etc.) Post-Graduate Training certificate (apprenticeship, residency, or equivalent) Active Professional License* Letter of Support - Request a letter of recommendation from your employer, supervisor, mentor, or a close colleague. The writer of the letter should speak to your level of expertise and commitment to patient care. It should be on letterhead and include the writer's full name, credentials, title, and contact details. Personal statement (not to exceed 2 -3 pages) - In this statement, be sure to answer the following questions: What first attracted you to go into your chosen profession? What do you enjoy most about the work you do? Why do you want to be admitted to the AIHM Fellowship? How will you use the knowledge and experience gained during this Fellowship to transform your practice, organization and/or community? (this question is essential for scholarship applicants) * Note: All documents in any language other than English must be officially translated into English. Additional Required Documents for Scholarship Applicants: A 2nd Letter of Support (same guidelines as the 1st letter. See above.) Tax Return Transcript - Request your most recent year's tax return transcript or you may submit your recent tax documents which show your adjusted gross income (AGI) and the number of dependents you have. If your income has significantly decreased since you filed your taxes, please indicate that in your personal statement. It may be a general statement and mention the percentage of the decrease. We do not require a detailed breakdown of your income and expenses/budget. For your protection, please block out / cover any social security numbers from documents before scanning and uploading them. If your profession does not require one of the required certificates or documents, please upload a word document with a statement such as this: "My profession does not require this." AIHM Fellowship Application Duplicate for ZBrains Part 2: Contact Information Name * First Last Invalid value Credentials * Invalid value Specialty * Invalid value Email (Please use a personal email address. Over time, you may change employers.) * Invalid value Cell Phone * ### - ### - #### Invalid value Office/Work Phone ### - ### - #### Invalid value Address * Street Address City State/Region/Province Postal / Zip Code -Select- Åland Islands Afghanistan Akrotiri Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Islands Australia Austria Azerbaijan Bahrain Bangladesh Barbados Bassas Da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Coral Sea Islands Costa Rica Cote D'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Dhekelia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Juan De Nova Island Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wake Island Wallis and Futuna West Bank Western Sahara Yemen Zambia Zimbabwe Country Invalid value What time zone do you live in? * Eastern Time Central Time Mountain Time Pacific Time Hawaii Standard Time Other Invalid value When would you like to begin the Fellowship * October 2022 April 2023 Invalid value I am an international applicant * No, I reside in the USA Yes, I am in international applicant Invalid value International Students Confirmation * Invalid value Please check to agree to the statement below. I acknowledge that the program is taught completely in English, involves both writing and speaking, and that I may be asked to submit evidence of English proficiency. Since April 2020, all AIHM Fellowship requirements have bee offered virtually. The retreats are offered virtually. There is an optional in-person clinical immersion for an additional, nominal fee. If you choose to not travel or pay the additional fee, we have a virtual clinical option. How did you hear about us? * AIHM Conference AIHM Email / Newsletter AIHM Fellows AIHM WebsiteACIH (Formerly ACCAHC) Conference - Other than AIHM's conference Facebook Google Fellowship Brochure Friend or Colleague Internet Search LinkedIn Twitter Invalid value Select all at that apply Please indicate which conference here Invalid value Name of the person who referred you Invalid value Tuition Discount Code Invalid value AIHM Fellowship Application Duplicate for ZBrains Part 3: Personal Data & Professional Information Date of Birth * MM/dd/yyyy Invalid value What is your current gender identity? * -Select- Female Male Transgender Trans-female Trans-male Gender Fluid Prefer not to specify Prefer to self identify as: Invalid value Prefer to self identify as: Invalid value Please specify gender identity Race and Ethnicity American Indian or Alaska Native (Eg: Navajo Nation, Blackfeet tribe, Mayan, Aztec, Nome Eskimo Community, etc) Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc) Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc) Hispanic, Latino, or Spanish Origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, etc) Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc) Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc) White (Eg: German, Irish, English, Italian, Polish, French, etc) Prefer not to specify Other (Please specify) Invalid value Which category best describes you? Select all that apply if you are biracial or multiracial. Race and Ethnicity Invalid value Please specify other The Academy of Integrative Health and Medicine (AIHM) is committed to maintaining an inclusive community that values diversity and fosters tolerance and mutual respect. We embrace and encourage our community differences in Age, Disability (physical and mental), Gender (or sex), Gender Identity (including transgender), Gender Expression, Genetic Information, Marital Status, Medical Condition, Nationality, Race or Ethnicity (including color or ancestry), Religion (or Religious Creed), Sexual Orientation, and Veteran or Military Status, and other characteristics that make our community unique.[1] All Students (prospective, current Fellows, and alumni) have the right to participate fully in AIHM programs and activities free from Discrimination, Harassment, and Retaliation. AIHM prohibits Harassment of any kind, including Sexual Harassment, as well as Sexual Misconduct, Dating and Domestic Violence, and Stalking. Such misconduct violates organizational policy and may also violate state or federal law. Primary Profession * Advanced Practice Registered Nurse (APRN) Bachelor of Ayurvedic Medicine and Surgery (BAMS) Certified Clinical Nutritionist (CCN) Certified Healing Touch Practitioner (CHTP) Certified Nutritional Specialist (CNS) Certified Nurse Midwife (CNM) Certified Physician Assistant (PA-C) Certified Professional Midwife (CPM) Certified Yoga Therapist (C-IAYT) Clinical Hypnotherapist (CHt) Chiropractor (DC) Direct-entry-midwife (DEM) Doctor of Acupuncture (DAC) Doctorate of Acupuncture & Oriental Medicine (DAOM) Doctor of Dentistry (DDS) Doctor of Medical Dentistry (DMD) Doctor of Oriental Medicine (DOM) Doctor of Philosophy (PhD) Doctor of Podiatric Medicine (DPM) Doctor of Pubic Health (DrPH) Doctor of Veterinary Medicine (VMD) East Asian Medicine Practitioner (EAMP) Family Nurse Practitioner (FNP) Healing Touch Certified Practitioner (HTCP) Licensed Acupuncturist (LAc) Licensed Clinical Social Worker (LCSW) Licensed Marriage and Family Therapist (LMFT) Licensed Midwife (LM) Licensed Practical Nurse (LPN) Licensed Professional Counselor (LPC) Licensed Vocational Nurse (LVN) Licensed Massage Therapist (LMT) Master of Public Health (MPH) Master of Science in Acupuncture and Oriental Medicine (MSAOM) Medical Doctor (MD) Naturopathic Physician (ND, NMD) Nurse Practitioner (NP) Osteopathic Doctor (DO) Occupational Therapist (OT) Pharmacist (Pharm D) Psychologist (PhD) Psychologist (PsyD) Physician Assistant (PA) Physical Therapist (PT) Registered Dietictian (RD) Registered Nurse (RN) Registered Pharmacist (RPh) Resident Student Other Invalid value IF you are an MD or DO in the US, do you intend to apply for ABOIM certification? * Yes No Invalid value What are your current board certified specialties? * Invalid value For the next set of questions, we rely on honesty and trust that the information provided is accurate to the best of your knowledge. Any omission or falsification of information about your license is grounds for immediate dismissal. In the past 10 years, has your license to practice in your field ever been subject to disciplinary action or been revoked, suspended, or placed on probation? * Yes No Invalid value If yes, please share your story with us. Invalid value In the past 10 years, have you ever been convicted of, or pled guilty or no contest to ANY offense in the U.S., its territories, or a foreign country? * Yes No Invalid value If yes, please share your story with us. Invalid value Is any criminal action pending against you, or are you currently awaiting judgment and/or sentencing following any entry of a plea or jury verdict? * Yes No Invalid value If yes, please share your story with us. Invalid value Are there any open inquiries on your professional license by any regulatory authority? * Yes No Invalid value If yes, please share your story with us. Invalid value Do you have any condition that may in any way impair, impact, or limit your ability to participate in this program? * Yes No Invalid value Social Media Accounts LinkedIn - Please enter your LinkedIn public profile URL Invalid value Facebook - Please enter your Facebook profile URL Invalid value AIHM Fellowship Application Duplicate for ZBrains Part 4: Document Uploads Thank you - your application is almost complete. Please upload the documents listed below. Please include your last name in the document name. Example: CV_LastName Headshot_LastName Diploma_LastName Certificate_LastName License_LastName Letter_LastName PersonalStatement_LastName Curriculum Vitae / Resume * Choose any file for this field. Please name your file as follows: CV_LastName Headshot * Choose any file for this field. Please name your file as follows: Headhsot_LastName Professional School Diploma* that is US Department of Education recognized or its foreign equivalent (such as MD, ND, PA, NP, DC, LAc, etc.) * Choose any file for this field. Please name your file as follows: Diploma_LastName Professional License (Active) * Choose any file for this field. Please name your file as follows: License_LastName Post-Graduate Training certificate (apprenticeship, residency, or equivalent) * Choose any file for this field. Please name your file as follows: LastName_Certificate Letter of Support * Choose any file for this field. Please name your file as follows: Letter_ LastName Personal Statement * Choose any file for this field. Please name your file as follows: PersonalStatement_LastName. The personal statement is the most important part of your application because it allows us to get a better sense of YOU! (1200 word limit) AIHM Fellowship Application Duplicate for ZBrains Part 5: Scholarship Application (Optional) AIHM offers need-based scholarships to a limited number of qualified applicants. Each cohort has a certain dollar amount for scholarships and once the funds are awarded, there are no more scholarships for that cohort. If you are interested in being considered for a scholarship, apply sooner rather than later! Criteria for scholarship awards includes verified financial need, the strength of the personal statement, and a letter of support from an employer, mentor or close colleague. Some scholarships require that additional criteria be met. In order to be considered for a scholarship, applicants must verify income by submitting a tax return transcript and/or other tax documents showing the household's adjusted gross income (AGI), plus the total number of dependents. Would you like to be considered for an AIHM scholarship? * Yes, I would like to apply. No, I would like to proceed without applying for a scholarship Invalid value If I am awarded a scholarship, I give permission for my name and photo to be used in a press release, on the AIHM website, etc. * Yes, I give permission No, I prefer not to have my name and photo published Invalid value Which scholarship would you like to be considered for at this time? * General Scholarship Fund - Underrepresented Professions (PAs, NPs, MSNs, LCSWs, LAcs, PharmDs, etc.) General Scholarship Fund - MDs and DOs Active Duty Military or Veteran or Provider Working with Veterans Scholarship Fund International Scholarship Fund Social Impact Clinical Scholarship Program (working with an AIHM partnered site) George Fellow Scholarship (Minnesota-based providers only) I am not certain and will allow AIHM's scholarship committee to select the best one for me. Invalid value Some of these scholarships are offered for every cohort, while others are offered depending upon funding. If you select one that is not available at this time, AIHM will offer the best option to you at the time you apply. I work with the underserved in this capacity: * Full-Time Part-Time I do not work with the underserved. Invalid value I am from and/or work with Black, Indigenous, and People of Color (BIPOC) communities. * Yes No Invalid value For those applying for the Clinicians Working for the Underserved Scholarship, locate your Medically Underserved Area/Populations (MUA) five-digit identification number and enter it here. Invalid value If you do not know this, please enter 12345. An Additional Letter of Support is Required to for Scholarship Applicants * Choose any file for this field. Request and obtain a letter from your employer, supervisor, mentor, or close colleague who can speak to your level of expertise and commitment to care. Tax Transcript or Official Tax Documents * Choose any file for this field. This must reflect your adjusted gross income (AGI). Please block out any/all social security numbers before uploading! I attest that this information is true, accurate, and complete and understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability. * Yes, I attest. Invalid value Part 7: Tuition and Fees The 2022 AIHM Fellowship in Integrative Health & Medicine tuition and fees are as follow: $200 non-refundable application fee. This will be due at the time you submit this application. $2,000 non-refundable holding fee. This is due upon acceptance to secure your spot in the class. $24,000 tuition for the two year Fellowship program. Applicant Fee Code Invalid value Application Fee USD Invalid value SUCCESS ! You Have Successfully Signed Up
