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WIM Fellow Application Form - 2026

The Women in Medicine Fellowship is a high-impact leadership experience designed for early and mid-career women across healthcare. Through two concurrent cohorts, the program brings together physicians and leaders from clinical and non-clinical disciplines to strengthen leadership capacity and expand influence across the healthcare ecosystem.

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Personal Profile

Please, provide your personal information

Question 2 of 32

Your Full Name

Question 3 of 32

Home mailing address

Question 4 of 32

Mobile phone number

Professional Credential(s)

(e.g. MD, DO, RN, PharmD etc)

Question 6 of 32

Professional Credential(s)  (e.g. MD, DO, RN, PharmD etc)

Question 7 of 32

Current role / title

Question 8 of 32

Organization

Question 9 of 32

Organization type

(Select all that apply)
A

Academic

B

Health System

C

Community/District/County

D

Private

E

Military

F

Industry

G

Other

Question 10 of 32

Years in practice/career

A

0-2 years

B

3-5 years

C

6-10 years

D

10+ years

Leadership scope

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Question 12 of 32

Do you have direct reports?

A

Yes

B

No

Question 13 of 32

Budget responsibility 

(Select all that apply)
A

N/A

B

$0-250K

C

$250K-1M

D

>$1M

E

Other

Demographics

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Question 15 of 32

Age range

A

25 - 34

B

35 - 44

C

45 - 54

D

55+

E

Other

Question 16 of 32

Gender identity

A

Woman

B

Man

C

Non-binary

D

Transgender

E

Prefer not to say

F

Other

Question 17 of 32

Race / ethnicity

A

Native American

B

Asian or Asian American

C

Black or African American

D

Hispanic, Latino, or Latina

E

Middle Eastern or North African

F

Native Hawaiian or Pacific Islander

G

South Asian

H

Southeast Asian

I

White or European American

J

Multiracial or mixed heritage

K

Alaska Native

L

Prefer not to say

M

Other

Question 18 of 32

Anything else you would like to share?

Career Goals

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Question 20 of 32

Career Interests

(Select all that apply)
A

Executive leadership

B

Academic leadership

C

Clinical leadership

D

Policy/advocacy

E

Strategy

F

Quality/performance

G

improvement/patient safety

H

Entrepreneurship

I

Other

Question 21 of 32

Desired next role (within five years)

Prior development

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Question 23 of 32

Previous leadership programs completed

Question 24 of 32

Previous leadership coaching experience

A

Yes

B

No

Question 25 of 32

Previous leadership assessments completed

A

DiSC

B

Hogan

C

Emergenetics

D

Kolbe

E

Gallup CliftonStrengths (formerly StrengthsFinder)

F

None

G

Other

Document Upload

Please, upload your document in this section

Question 27 of 32

Your Statement of Purpose from the applicant

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Question 28 of 32

A Letter of Recommendation from a sponsor or senior leader who can speak to their readiness for advancement

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Question 29 of 32

Your current CV

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Organizational support

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Question 31 of 32

Program participation:

 

I have reviewed the program schedule, including all session dates, times, and locations, and commit to attending each session and engaging fully in the learning, discussion, and community experience throughout the WIM Fellowship. I also acknowledge that meaningful participation extends beyond scheduled sessions and includes time dedicated to reflection, preparation, reading, and intentional relationship building with fellow participants and faculty, and within my professional network. (Accommodations can be made on an individual bases)

A

Yes

B

No

Question 32 of 32

Is your organization sponsoring your participation?

A

Yes

B

No

C

Other

Confirm and Submit