MVH TENDING THE FLAME PROGRAM 2019-20

MVH Application for the Tending the Flame/RISHI Resiliency Curriculum Training Program 2019-20

1. Name and Education History *This question is required.

First Name
Last Name
Advanced Degree
School
Year of Graduation
License #
State of Issue

2. Professional Specialty *This question is required.

3. Professional Institution or Affiliation *This question is required.

Institution/Affiliation
Title
Professional Role
Years in Position
Employed Physician or Private Practice

4. Work Contact Information *This question is required.

Name
Address
City, State, Zip
Work Phone
Mobile Phone
Preferred Email

5. Are you a member of a resident or physician wellness program? If so, what is your role?

6. Why are you considering taking this year long program, at this time, in your professional career?

7. What do you hope to gain from this program professionally? *This question is required.

8. What do you hope to gain from this program personally? *This question is required.

9. Do you have any experience in leading small groups or workshops? *This question is required.

10. Please tell us one way that being a physician has enriched your life. *This question is required.

11. Is there anything else you would like us to know? *This question is required.

CME credit for this workshop training will be forthcoming.

THANK YOU!
Thank you for applying for the RISHI MVH Tending the Flame Training Workshop. Your application will be reviewed and you will be contacted within a few weeks by the RISHI Director, Evangeline Andarsio, MD .