Apply to Harvard Macy - Educators Course Step 1 of 7 - Account Information 14% Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Suffix Email(Required) Mobile Number(Required) Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about this course?(Required)Please select an optionHMI Alumni or Community MemberColleagueInstitutional Sponsor or HMI- Affiliated ProgramHMI NewsletterHMI EmailHMI Mailer/PostcardHMI WebsiteLinkedinGoogle/Bing SearchHMS WebsiteOtherIf you selected HMI Alumni or Community Member, please share their name(s) so we can thank them. If you selected Other, please specify: Are you an Alumnus of the Harvard Macy Institute? Yes No Please let us know which course(s) you have completed. Leading Innovations In Health Care & Education A Systems Approach to Assessment in Health Professions Education Transforming your Teaching using Technology Will you be self-funded to attend this program or is your institution or another sponsor funding you to participate in this program?Self-FundedInstitution or Sponsor-FundedOtherIf other, please specify: Institution or Sponsor Name: Contact Email for Institution/Sponsor: Billing Address for Sponsor Institution: GenderPlease select an optionFemaleMaleNon-binary / Unspecified (X)Undisclosed (U)Timezone(Required)Greenwich Mean TimeUniversal Coordinated TimeEuropean Central TimeEastern European Time(Arabic) Egypt Standard TimeEastern African TimeMiddle East TimeNear East TimePakistan Lahore TimeIndia Standard TimeBangladesh Standard TimeVietnam Standard TimeChina Taiwan TimeJapan Standard TimeAustralia Central TimeAustralia Eastern TimeSolomon Standard TimeNew Zealand Standard TimeMidway Islands TimeHawaii Standard TimeAlaska Standard TimePacific Standard TimePhoenix Standard TimeMountain Standard TimeCentral Standard TimeEastern Standard TimeIndiana Eastern Standard TimePuerto Rico and US Virgin Islands TimeCanada Newfoundland TimeArgentina Standard TimeBrazil Eastern TimeCentral African TimeLinkedIn Profile Link Degree(s)(Required)Specialty/Specialties(Required) Note: Enter your professional specialities - if not applicable, enter NAAcademic Title(Required) Note: Enter your academic title - if not applicable, enter NAProfessional Institution Affiliation(Required) Note: Enter the name of your institution/business/organization - if not applicable, enter NA.Professional School Affiliation(Required) Note: Enter the name of your school - if not applicable, enter NA.Professional Organization Affiliations Add RemoveEnter any professional organizations for which you are a member. Select '+' to list additional affiliations. Education and Professional Experience(Required)Scholarly Interest(Required)Personal Background(Required) Briefly describe why you want to attend this program and list 1-3 goals you hope to achieve by participating.(Required)(750 character maximum)Project(Required)Please provide a concise, thoughtful overview of the institutional project or problem you hope to address during this course with the following included: • Project Title • Project Description (Please include project goals and what question, concern, problem, or situation is addressed by your project) • Project Context (Please include number of individuals who will be impacted by your project. Which key leaders, stakeholders, participants, and/or systems will influence its success? What barriers, if any, do you anticipate in completing this project?) • Project Outcomes: (What outcome(s) will define success for your project, and what is the plan for measuring those outcomes? It is permissible for a group of applicants to work on the same project. If you are part of such a team, please enter the names of your other team members:What target population will your project implementation effect?(Required) Undergraduate Graduate Continuing Professional Development Other Please specify: What is the primary area of focus for your project?(Required) Teaching and Education Curriculum Design Faculty Development Assessment and Evaluation Educational Technology Learn Support Other If you selected Other, please specify: Are you applying as part of an HMI affiliated program?YesNoIf Yes, Select from the drop down:Macy Foundation Faculty Scholars ProgramKern Foundation KNN-HMI Faculty Scholars ProgramArnold P. Gold Foundation Faculty Scholars ProgramUniversity Global Health Equity (UGHE)Boston Children's Global ScholarsHMS MastersMGH IHP MastersOtherIf you selected Other, please specify: CAPTCHA