Stanford University Community Health Advocacy Fellowship
Application Form 2014-2015
Applications will be accepted on a rolling basis until September 5, 2014 or until spaces are filled
Please submit your application as a PDF to chafellows@gmail.com
Name:
Current year/major:
Email:
Phone #:
1. Why are you interested in the Community Health Advocacy Fellowship? (500 words or less)
2. As a Community Health Advocacy Fellow, what personal attributes, skills, or experiences would you contribute
to a community partner organization and to your peers in the fellowship cohort? (500 words or less)
3a. Of the remaining available placement sites, please rank your preferences (1st, 2nd, 3rd, etc.). Include rankings
for all placements that interest you. If you do not wish to be placed with a certain partner, do not rank it.
_____Arbor Free Clinic
_____Boys and Girls Club
_____Day Worker Center
MayView @ Palo Alto
MayView @ Mountain View
_____Pacific Free Clinic
___ Puente de la Costa Sur
________ Samaritan House Free Clinic
_________Second Harvest Food Bank
___ Stanford Health Advocacy & Research Program
________No preference
3b. (optional) Please briefly describe reasons for your preference rankings.
4. Please list any program-related courses that you have taken or plan to take. Please note when you have taken
or plan to take MED157.
5. Spanish proficiency is required or strongly recommended for some community partner sites and projects (see
Program Description for specific information).
Please report your Spanish-speaking proficiency on the following scale:
1
(Unable to
converse)
2
3
(Comfortable with
basic
conversation/
expressing
simple ideas)
4
5
(Very comfortable
expressing
yourself/
comprehending
dialogue)
6
7
(Native
fluency)
If you speak another language, please report your speaking proficiency in that language.
Language: ________________ 1
2
3
4
5
6
7
6a. Do you have access to a car to drive to your community partner site? __ Yes __ No
6b. Are you willing to take public transportation to your community partner site? __ Yes __ No
7. What other activities will you be involved in during the 2014-15 academic year, and how much time do you
expect to devote to them?
8. Please list contact information for two references. (Include full name, relation to applicant, email, and phone)
9. Please attach a current resume and transcript.
The requirements of the Community Health Advocacy Fellowship are described in detail at
http://och.stanford.edu/training/community.html. Please review these carefully before submitting your
application.
My signature below indicates that I have read and agree to accept the responsibility and commitment
required of students in the Stanford Community Health Advocacy Fellowship.
Signature: _________________________________________
Date: _______________