Community Health Worker Career Pathways Program

Program Application and Eligibility Form

Thank you for your interest in the Community Health Worker Training Program. Please complete this initial on-line form and provide contact information.  We will inform you about upcoming CHW training courses in 2024.


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* 1. Today's Date

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* 2. Please provide contact information.

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* 3. In case of an emergency, please provide an emergency contact/

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* 4. What is your date of birth?

Date

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* 5. What is your gender?

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* 6. What are your preferred pronouns?

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* 7. What is your race?

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* 8. What is your ethnicity? (Please select all that apply.)

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* 9. Educational Attainment Level (check all that apply)

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* 10. Marital Status

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* 11. How many people currently live in your household, including yourself?

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* 12. How many dependents under 18 years of age do you have?

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* 13. How many of your children are under 5 years?

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* 14. What is your citizenship status?

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* 15. What is your country of origin?

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* 16. Please indicate if the following applies to you.  If you check yes to any of the statements, we will provide you with additional information and support through the training program.  (Please select all that apply.)

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