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2025 THA Leadership Fellows Application

Biographical Information

1. First Name *This question is required.

2. Last Name *This question is required.

3. Degrees *This question is required.

4. Designations *This question is required.

5. Title *This question is required.

6. Company/Organization Name *This question is required.

7. Address *This question is required.

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

8. Phone *This question is required.

9. Email *This question is required. This question requires a valid email address.

10. Current Position by General Role *This question is required.

11. Hospital Ownership *This question is required.

Investor-Owned
Public/Government-Owned
Not-for-profit
Partnership

12. Hospital Type *This question is required.

Urban
Rural
Suburban
Critical Access
Academic Medical Center
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

13. Hospital Size *This question is required.

Under 100 Beds
101-500 Beds
500+ Beds

14. Please select your gender identity: *This question is required.

Please enter an 'other' value for this selection.

15. Age: *This question is required.

16. Race and Ethnicity*:
(*Options determined based on proposed U.S. Census categories). May select multiple categories . *This question is required.

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.