Community Health Worker Certification Program

APPLICATION

- Provide an Photo copy of your identification and your resume with your application.

- Program details at https://healthcareaccessnow.org/programs/community-health-worker-job-training/

- Admittance to the program requires an online career assessment and a copy of your driver's license and high school diploma or GED BEFORE being accepted into the program. Look for directions to take the career assessment after you submit this application.

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* 1. Select one session.

Days/Time: Mondays and Fridays, 9 a.m. to 1:30 p.m.
(Evening classes 5p.m.-8:30p.m.:Tuesdays and Thurdays)

March 17,2025 Spring Cohort

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* 2. ADDITIONAL CERTIFICATION OPPORTUNITY: Optional certificates are available. Please indicate whether you plan to participate in an additional training. Fees apply. Download the MHFA Training brochure for more information.

CPR Training - $90

Mental Health First Aid Training - $170

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* 3. A 130-hour community-based practicum is required by the Ohio Board of Nursing for certification. Will you be completing your practicum where you work or will you need a placement?

I will complete my practicum hours at my current place of employment.

I will need a placement to complete the practicum hours.

Other (please specify)

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* 4. How did you hear about the HCAN CHW Certification Training Program?

My Employer

HCAN Staff Member

HCAN Website

Facebook

Instagram

Other (please specify)

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* 5. Name

First Name

Last Name

Preferred Name

Previous Name (if any)

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* 6. Contact Information

Address *

Address 2

City/Town *

State *

ZIP Code *

Email Address *

Phone Number *

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* 7. Personal Data

Date of birth (MM/DD/YYYY)

Last 4 digits of SSN

Gender

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* 8. Which race/ethnicity best describes you? (Please choose only one)

American Indian or Alaskan Native

Asian or Asian American

Native Hawaiian or other Pacific Islander

Hispanic or Latinx

Black or African American

White or Caucasian

Multiple ethnicity / Other - Please specify:

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* 9. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic or Latinx Group?

I am not Spanish, Hispanic, or Latinx

Mexican

Mexican-American

Chicano

Puerto Rican

Cuban

Cuban-American

Some other Spanish, Hispanic, or Latinx group

From multiple Spanish, Hispanic, or Latinx groups

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* 10. Military Service - have you ever served or are you now serving in the military?

Yes

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* 11. Emergency Contact

Name of emergency contact

Relationship to contact

Phone number

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* 12. Academic Information

High School

Graduation Date

Did you receive a GED?

If yes, list the date

College

Major

Graduation Date

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* 13. Employment History - Current or Most Recent

Employer Name

Employer Address

Position Title

Date of Employment

Reason for Leaving

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* 14. Employment History - Job 2

Employer Name

Employer Address

Position Title

Date of Employment

Reason for Leaving

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* 15. Personal Statement
Why are you interested in going through this program and what are your expectations?
300 words or less

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* 16. THREE Professional/Personal References (cannot be family members)

Name of FIRST Reference

Address

Phone

Name of SECOND Reference

Address

Phone

Name of THIRD Reference

Address

Phone

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* 17. What is your planned method of payment? HCAN accepts Visa, MasterCard and Discover, cashier checks, employer checks, and cash payment . No personal checks, scholarships are on an as NEEDED bases.

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* 18. INVOICE - If your employer or a company is paying the tuition, provide contact information for the person that should receive the invoice.

Company name

Contact name

Contact's email

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* 19. Let us know here if there is anything else you wish to share.

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* 20. Upload Photo copy of any form of Identification

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 21. Upload copy of your resume and/or recomendation letter.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Your application is complete upon receipt of the application fee. Check your email for the payment link, emailed in 1-2 business days, or go to the healthcareaccessnow.org webpage to pay now with a credit card online or with a cashier's or employer's check (personal checks not accepted).

When you click 'APPLY' your application will be submitted. Thank you!!

Community Health Worker Certification Program

APPLICATION

Question Title

* 1. Select one session.Days/Time: Mondays and Fridays, 9 a.m. to 1:30 p.m.(Evening classes 5p.m.-8:30p.m.:Tuesdays and Thurdays)

Question Title

* 2. ADDITIONAL CERTIFICATION OPPORTUNITY: Optional certificates are available. Please indicate whether you plan to participate in an additional training. Fees apply. Download the MHFA Training brochure for more information.

Question Title

* 3. A 130-hour community-based practicum is required by the Ohio Board of Nursing for certification. Will you be completing your practicum where you work or will you need a placement?

Question Title

* 4. How did you hear about the HCAN CHW Certification Training Program?

Question Title

* 5. Name

Question Title

* 6. Contact Information

Question Title

* 7. Personal Data

Question Title

* 8. Which race/ethnicity best describes you? (Please choose only one)

Question Title

* 9. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic or Latinx Group?

Question Title

* 10. Military Service - have you ever served or are you now serving in the military?

Question Title

* 11. Emergency Contact

Question Title

* 12. Academic Information

Question Title

* 13. Employment History - Current or Most Recent

Question Title

* 14. Employment History - Job 2

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* 15. Personal Statement Why are you interested in going through this program and what are your expectations?300 words or less

Question Title

* 16. THREE Professional/Personal References (cannot be family members)

Question Title

* 17. What is your planned method of payment? HCAN accepts Visa, MasterCard and Discover, cashier checks, employer checks, and cash payment . No personal checks, scholarships are on an as NEEDED bases.

Question Title

* 18. INVOICE - If your employer or a company is paying the tuition, provide contact information for the person that should receive the invoice.

Question Title

* 19. Let us know here if there is anything else you wish to share.

Question Title

* 20. Upload Photo copy of any form of Identification

Question Title

* 21. Upload copy of your resume and/or recomendation letter.

* 1. Select one session.

Days/Time: Mondays and Fridays, 9 a.m. to 1:30 p.m.
(Evening classes 5p.m.-8:30p.m.:Tuesdays and Thurdays)

* 15. Personal Statement
Why are you interested in going through this program and what are your expectations?
300 words or less