BCPH Universal Application Form
I am applying for the following:
40 Under 40 - African Continent (Due March 7, 2026)
40 Under 40 - North America (Canada, U.S., and Mexico) (Due March 14, 2026)
40 Under 40 - Europe (Due March 21, 2026)
40 Under 40 - Asia and AustralAsia (Due June 13, 2026)
40 Under 40 - Central and South America (Due July 11, 2026)
Distinguished Career in Public Health - Worldwide (Due August 10, 2026)
Outstanding Practice in Public Health - Worldwide (Due September 15, 2026)
Health Innovators - Worldwide (November 7, 2026)
Primary Email
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Secondary Email
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example@example.com
Name
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First Name
Last Name
Pronouns
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State
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Country of Residence
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Country of Origin
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Title
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MD/DO
ScD/SD/DSc
PhD
JD
MA
MS/MPH
Other
Mobile Number for SMS
Current Professional Position (e.g., Student, Professor)
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Organizational Affiliation
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Area(s) of public health/health and social justice focus (Select all that apply.):
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Health policy
Health management
Maternal and Child Health
Reproductive and sexual health
LGBTQ+ Health
Men's Health
Women's Health
Substance Use, Abuse, and Addiction
Refugee/Immigrant Health
Infectious diseases
Environmental health
Occupational health
Dental Health
Global Health
Disability
Other
Professional Biography
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Personal Statement describing you background, health innovation, and its alignment with BCPH's vision to advance equity and social justice (500-1000 words, max)
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Upload CV
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LinkedIn URL
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Other relevant links and information (Social media channels, personal professional website):
Are you a member of the Boston Congress of Public Health? You may apply without a membership, but if awarded the fellowship, a membership must be purchased. More information: https://bcph.org/membership/.
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Yes
No, but I'd like to learn more and apply here: https://bcph.org/membership.
Demographics
Below are some background questions that help us tailor our programming. You are not obligated to answer.
Gender: I identify as (click all that apply):
Man
Woman
Non-Binary
Trans gender
X
Other
Race: I identify as (click all that apply):
White
Black or African American
Asian
American Indian and Alaska Native
Native Hawaiian and Other Pacific Islander
Other
I am /was the first person in my family to go to college.
Please Select
Yes
No
Age
Under Age 18
18-21
22-25
26-29
30-34
35-39
40-44
45-49
50-54
55-59
60+
Please verify that you are human
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Payment
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40 Under 40 App Fee - Africa
$
15.00
40 Under 40 App Fee - North America, Central/South America, Europe, Asia/AustralAsia
$
35.00
Health Innovators App Fee - Worldwide
(Regular submission fee is $35.00)
$
35.00
Outstanding Public Health Practice Award - Worldwide
$
20.00
Distinguished Public Health Award - Worldwide
(Regular submission fee is $20.00)
$
20.00
BCPH Public Health Grant Award - Worldwide
(Regular submission fee is $20.00)
$
20.00
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