SELF 2.0 Application Form - The Association for Surgical Education

This is the application for the ASE Surgeon Empowerment Leadership Fellowship (SELF 2.0) program. If you wish to apply for the research fellowship (SERF) program, visit: https://www.surgicaleducation.com/surgical-education-research-fellowship-overview/

Application Form

Name(Required)

First Last Degree(s)

Email(Required)

Institution(Required)

Institution Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

How many years have you been out of training?

Please note this course is intended for individuals at least 5 years out of training.

Select all that apply:(Required)

PhD

Other

If Other, please explain:

Gender Identity

Please describe your gender identity:

Ethnicity

Please list the ethnicity(ies) you most identify with:

* Note: The gender and ethnicity questions are asked to help make a diverse and inclusive fellow cohort.

Supporting Documents

Please merge all files in to ONE pdf and upload as a single document. The following must accompany your application:

1. A one to two page statement of interest in medical education, which includes:
Current activities/responsibilities in medical education
Current and/or near future leadership roles
Specific areas of teaching performance, education design, or assessment you wish to improve

2. Letter of support from Department Chair or Program Director agreeing to commit to fund the cost of fellowship participation and allow time off for travel to SELF 2.0 sessions ($2500 (member)/$3000 (non-member) tuition plus costs incurred for travel and lodging at the required seminars).
3. A current copy of your curriculum vitae.

Supporting Materials(Required)

Accepted file types: pdf, Max. file size: 512 MB.

Please check this box to agree to the Course Fee of $2500 (member)/$3000 (non-member) as well as travel to SELF 2.0 workshops.(Required)

Course Fee: $2500 (member)/$3000 (non-member)