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Application

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DEADLINE for applications: January 31, 2025.
Please complete this application in one session, progress cannot be saved.

Name*

Credentials*

Title / Leadership Role* (formal or informal leadership role)*

Email (this email will be our primary way of corresponding with you)*

Date of Birth*

Cell Phone Number*

Clinical Specialty Area*

Clinic / Primary Facility*

Medical Group

Years of Service with CHI / Dignity Health*

Years in Current Role*

State*

Gender

Ethnicity

Executive Sponsor

In order to be considered for this program, we require that an executive (e.g. a medical group CMO, a medical group VP of Operations, etc.) endorses your participation in this program. Please provide their information in the fields below.

Executive Sponsor Name*

Executive Sponsor Email (for confirmation)*

Executive Sponsor Title*

Essay (approximately 300-500 words. Do not exceed 750 words)

Your essay will be thoroughly evaluated and has significant determination in your potential admission to the Provider Leadership Academy. We strongly recommend you review your essay with your endorsing executive leader. For guidance, tips or feedback on your essay, you can email advancedpractice-communications@commonspirit.org. Choose ONE of the following topics, and upload your essay below.

Chosen Topic

Describe your leadership journey and/or leadership philosophy. How has leadership shaped your current role, and how do you anticipate leadership to play a role in your future?

At the end of this program, what outcomes do you plan to achieve personally, professionally, and/or for the broader organization? (for example: For your team? For the organization and communities we serve? What would success look like for those you work with?)

Why are you a good candidate for this program? What is your single biggest motivator for participating in the Provider Leadership Academy at this time?

Essay Grading Rubric

Essays will be graded on the following attributes:

Grammar/Spelling 25%
Content 25%
Clarity 25%
Passion/Potential for Leadership 25%

Upload essay file below:

Upload essay file below:*

Accepted file types: doc, docx, txt, pdf, rtf, Max. file size: 30 MB.

We suggest uploading a .pdf formatted essay to avoid file issues.

Name

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