CHIME Glaser Scholarship Award Form

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John Glaser Scholarship

Application Form

The following items must be included with your application form:

Scholarship essay.
1. This essay will address how the applicant and their organization would benefit from their attendance at the three programs included in the scholarship.
2. The essay will address what the applicant is doing to use IT to create a connected community in their area.
3. The essay will address what the applicant’s plans are for technology innovation at their organization.
4. Applicants should also include information related to any financial issues that would prevent them from otherwise attending the three programs included in the scholarship.
Letter of recommendation:
The CHIME member’s immediate supervisor must complete a letter of recommendation which supports the candidate’s application and their explanation of items a-d of the applicant essay.

I. Applicant Information (ALL fields required)
Applicant’s name:
CHIME Member Name*:
Title:
Organization:
Address:
City:
State:	Zip:
Email:
Job Responsibilities: Scholarship candidates must be employed in the same organization for the last 2 consecutive years (shows consistency and dedication). Do you meet this criteria? Yes No *Scholarship applicants must be staff of a current CHIME member.

You will be required to submit the above documents on the next page.

Questions or comments? Send an email to staff@cio-chime.org.

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Upcoming Events
	February 20, 2012 CHIME/HIMSS Spring CIO Forum Las Vegas, Nevada
	April 14-17, 2012 Healthcare CIO Boot Camp Gleacher Center at University of Chicago, Chicago, Illinois
	October 13-16, 2012 CHIME Healthcare CIO Boot Camp Renaissance Esmeralda Indian Wells, California
	October 16-19, 2012 CHIME12 Fall CIO Forum Renaissance Esmeralda Indian Wells, California

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