Governance Fellowship Application Governance Events Resources Board Chair Governance Governance Fellowship Governance Fellowship Application Membership Meetings Annual Membership Meeting HR Conference Member Forums Professional Development Clinical Faculty Academy and Nurse Preceptor Academy e-Learning Healthcare Leadership Academy Sponsorship & Advertising Class XXI/2024-2025 Application Thank you for your interest in applying for the MHA Excellence in Governance Fellowship. If you need assistance as you complete this application, please contact Erin Steward at the MHA or (517) 282-5639. COMPLETED APPLICATION INFORMATION A completed application includes: 1. Your answers to sections I - II of this application 2. A signed letter of support from your hospital chief executive officer SUBMITTING APPLICATIONS Completed applications and required materials should be submitted by June 28, 2024. Applications may be submitted using the electronic form below, with additional required materials emailed to esteward@mha.org. Alternatively, the application form may be completed and emailed or mailed with supporting materials to: MHA Excellence in Governance Fellowship MHA Health & Hospital Association 2112 University Park Dr., Okemos, MI 48864 SECTION I: APPLICANT INFORMATIONApplicant Name(Required) First Last Name preferred in informal setting Board on which the applicant serves Hospital/Healthcare Organization Address Street Address City ZIP Code Chief Executive Officer CEO PhoneCEO Email Name of CEO Assistant CEO Assistant Email Tuition invoice should be sent to Applicant Personal DataProfessional (work) Title Employer Preferred Address (home or work) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Phone Number to ContactBest Email to Contact(Please use the email address where you will want all fellowship correspondence to be delivered.) Spouse/Partner Name (if applicable) SECTION II: EXPERIENCE1. Please submit a current resume or curriculum vitae. 2. Board experienceNumber of years on current hospital/healthcare organization board Hospital/healthcare organization board committees on which you have served or are now servingOther civic/government board activitiesSECTION III: LETTER OF ORGANIZATIONAL SUPPORTYou are required to submit a letter of support from the healthcare organization’s chief executive officer indicating organizational support and commitment (time and resources) for your participation in the fellowship program. The MHA Health Foundation is the nonprofit section of the Michigan Health & Hospital Association, established to support hospitals and their community partners in improving the health of individuals and communities throughout Michigan. Copyright ©2001-2024 Michigan Health & Hospital Association and MHA Health Foundation. All rights reserved. No part of this piece or the MHA Excellence in Governance Fellowship program may be used or reproduced in any manner without written permission of the MHA Health Foundation. Note: Forms will not be accepted if they include URLs. Δ
