Participant Application

Please fill out the application below. Applications for each individual must be submitted, as we do not accept team applications.

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The deadline for applications is May 13th. Admissions will be sent out on a rolling basis, but we encourage you to get your application in as early as possible. Upon acceptance, we will send you an email.

- VA & MIT Hacking Medicine

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Personal Information

First name *

Last name *

Email *

Phone *

Age *

Preferred Pronoun *

Country of Residence *

State

City

Which of the following best describes your ethnic background? *

Select all that apply.

If you selected "other" to the previous question, please elaborate if you feel comfortable doing so

Are you active duty or a Veteran of the United States Military? *

Yes

What is your occupation? *

School / Company *

Write “N/A” if not applicable.

Job Title *

If you are a student, please put the degree being sought and the focus of your program (e.g. "MBA with a concentration in Innovation & Entrepreneurship").

What is your primary background? *

Additional background areas *

Check all that apply.

LinkedIn Profile URL

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Logistics

Will you be traveling from outside the United States to attend this event? *

Yes

Yes, and I require a visa

Will you require a room in our hotel block (we will hold a block of rooms in a local hotel and you can pay to stay as you wish)? *

Yes

Not sure

Do you have any accessibility needs that require accommodation for the Hackathon? *

Yes

If you selected yes in the previous question, please explain

Please list your dietary preferences *

We will do our best to accommodate everyone attending the event.

Emergency Contact

Name *

Email *

Phone *

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Additional Information

Select affiliation you have with VHA *

Preferred mode of contact *

How did you hear about this event? *

In the future, would you like to be contacted by our sponsors for opportunities that may be of interest to you? *

Yes

Have you been to a healthcare hackathon before? *

Yes

If yes, please list the names and years of the hackathons you've attended.

Please list each hackathon in its own line, and separate the hackathon name and year with a comma (ex. NYC Grand Hack, 2018)

Please check off any technical skills you are proficient in.

Please check off any team-based skills / attributes you have:

Please check off any clinical skills you have

Please briefly describe your experience and skills. *

In 200 - 500 characters, please share a little bit more about your background so we can ensure a diversity of skills at the event.

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Questions

Tell us about a healthcare problem that you care about. *

The issue can be as broad or narrow as you would like.

What are three things you are hoping to gain from this experience? *

In 300 characters, please tell us more about why you are applying to Grand Hack so we can better tailor the hack towards your interests.

Please share a time when you worked with a colleague with a different background and perspective than your own. How did you make sure to be inclusive of their views and identity? *

The VHA greatly values diversity and inclusion within our workspaces; numerous studies cite the importance of having a diverse and inclusive workspace to promote creativity, productivity, and knowledge sharing.

Can you make the entire event? *

Yes

The event takes place from 4pm-10pm Friday May 17th, 8am-10pm Saturday May 16th, and 8am-2pm Sunday May 17th [times are approximate Eastern Time].

When you attend the VHA Tampa Hackathon 2024, you will enter an area where photography, audio and, video recording may be taken. Event organizers may use, reproduce, and/or publish photographs, videos, and other media taken during the Hackathon for promotional, educational, and/or informational purposes, including but not limited to website content, social media, press releases, and marketing materials. Event organizers retain the right to use the images and recordings for an unlimited period. By submitting this form, you consent to the use, reproduction, and/or publication of media captured during the event. Do you acknowledge this? *

Yes

I acknowledge that if I am an employee of the US Department of Veterans Affairs, I am ineligible to receive a cash prize through my participation in the Veterans Health - MIT Hacking Medicine 2024. Do you acknowledge this statement? *

Yes

I acknowledge that if I am an employee for the US Department of Veterans Affairs, I am ineligible to receive Meals and Incidentals reimbursement as part of my VA-sponsored travel for meals where food will be provided. Do you acknowledge this statement? *

Yes

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Registration Confirmation

Please review your registration information prior to submitting the application. Click “back” to make any necessary changes.

Personal Information
First name
Last name
Email
Phone
Preferred Pronoun
Country of Residence
State
City
Which of the following best describes your ethnic background?
If you selected "other" to the previous question, please elaborate if you feel comfortable doing so.
Are you active duty or a Veteran of the United States Military?
What is your occupation?
School / Company Name
Job Title
What is your primary background?
Additional background areas
LinkedIn Profile URL
Logistics
Will you be traveling from outside the United States to attend this event?
Will you require a room in our hotel block (we will hold a block of rooms in a local hotel and you can pay to stay as you wish).
Do you have any accessibility needs that require accommodation for the Hackathon?
If you selected yes in the previous question, please explain.
Please list your dietary preferences.
Emergency Contact
Name
Email
Phone
Additional Information
Select affiliation you have with VHA
What is your preferred mode of contact during the hackathon?
How did you hear about this event?
In the future, would you like to be contacted by our sponsors for opportunities that may be of interest to you?
Have you been to healthcare hackathon before?
If yes, please list the names and years of the hackathons you've attended
Please check off any technical skills you are proficient in.
Please check off any team-based skills you have.
Please check off any clinical skills you have.
Please briefly describe your experience and skills.
Questions
Tell us about a healthcare problem that you care about.
What are three things you are hoping to gain from this experience?
Please share a time when you worked with a colleague with a different background and perspective than your own. How did you make sure to be inclusive of their views and identity?
Can you make the entire event?
Photography acknowledgement
Employee ineligibility acknowledgement
Employee reimbursement acknowledgement