Thomas J. Balkany Cochlear Implant Training Scholarship

Personal Information

Full namePreferred nameEmailPhone numberSelect your hearing healthcare professionWhere do you primarily reside?Mailing AddressProfessional Credentials/DegreesCurrent Professional Status

Professional Background

Current Employer/Institution *Position/TitleYears in Current Position *Total Years in FieldPractice/Clinical Setting *Current Cochlear Implant Experience *Estimated number of CI patients you currently serveGeographic Location of Practice *Do you primarily serve underserved or underrepresented populations?If yes, please describe.

Course Selection

Which ICIT course(s) are you applying to attend? *

Advanced Surgeons Course International Surgeons Course Advanced Audiology Course Foundational Audiology Course International Foundational Audiology Course Clinical Team Efficiency Course

Preferred Course DatesHave you previously attended any ICIT courses? *If yes, which courses and when?Why is this specific course important for your professional development? * (250 words max)

Financial Need Statement

Total Course TuitionScholarship Type Requested *Please describe your financial need and why scholarship assistance is necessary * (500 words max)Does your employer provide professional development funds? *If yes or limited, please explain what is available and why additional funding is needed:Are you applying for or receiving funding from other sources? *If yes, please specify source and amount:

Professional Development & Impact

How will completing this ICIT course impact your clinical practice? * (300 words max)How will this training benefit your patients and community? * (300 words max)What are your short-term and long-term career goals related to cochlear implantation? * (250 words max)Do you plan to mentor others or share knowledge gained from ICIT training? *If yes, how will you share knowledge?

Personal Statement

Please tell us your story * (500 words max)

Supporting Documents

Current CV or Resume *

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Letter of Recommendation - Recommender Name *Recommender Email AddressRecommender Relationship to You *

Certification

By submitting this application, I certify that:

All information provided is accurate

I agree to attend the full course if awarded

I understand falsification may result in disqualification

I will notify ICIT immediately if unable to attend after receiving award

I agree to provide testimonial/photo if requested (identifying info may be confidential)

I understand scholarship funds will be applied to tuition only

I authorize ICIT to verify information providedSignature

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Thank you for your interest.

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