MiCHWA CHW Ambassador Program Application

This year we are kicking off our new CHW Ambassador program in which we are seeking 10 CHWs, one from each region, to act as ambassadors with the goal of raising awareness for both CHWs and MiCHWA. Please complete this application in order to be considered for the MiCHWA CHW Ambassador Program. The application will close on February 26th and we will be holding interviews shortly after.

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* 1. Contact Information

Name *

Organization

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Demographic Information

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

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White

Choose not to identify

Multiple ethnicities / Other (please specify)

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* 3. Which of the following gender identities best describe you? (choose all that apply)

Female

Male

Transgender

Non-Binary

Prefer not to say

Other (please specify)

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* 4. Please list the language(s) in which you are proficient (read, write, and able to teach in)?

Language 1:

Language 2:

Language 3:

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* 5. MiCHWA hopes to find a wide variety of Ambassadors including an ambassador from each of our 10 regions. Using the picture below, please indicate which region you work in below.

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* 6. How many years of experience as a CHW do you have?

0-5 years

6-9 years

10+ years

MiCHWA Involvement

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* 7. Do you currently have an active MiCHWA Membership with access to the MiCHWA registry?

No - If no, please describe why in the comment box below.

Yes - If yes, are you in good standing (paid your fees, up to date/making progress on CEU requirements, etc.). Please answer in the comment box below.

Please explain your answer

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* 8. Are you a MiCHWA Certified CHW?

Yes

If yes when did you graduate?

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* 9. Are you a member of one (or more) of our workgroups?

Yes

If yes, which group(s)?

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* 10. Have you ever been awarded a MiCHWA scholarship?

Yes

Open-Ended Questions: In this section, we would like to get to know you and understand why more about why you are a good fit for the ambassador program.

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* 11. What have you gained from being a member of the MiCHWA Registry?

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* 12. What have you learned from being a CHW?

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* 13. Why do you want to be a MiCHWA Ambassador?

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* 14. As an ambassador MiCHWA will be sharing resources for you to share with your region and you will be providing resources for us to put out to the larger MiCHWA network. Please upload a current resource from your region. These resources might include, but are not limited to, COVID-19 testing sites, webinars, training opportunities, etc.

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

Choose File

Certification of Application

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* 15. I certify that the information submitted in this application is true and correct to the best of my knowledge.

I further understand that any false statements may result in the denial or revocation of this application.

Yes

Thank you for submitting your application for the MiCHWA Ambassador Program. The Ambassador Program Committee will be reviewing and selecting Ambassadors in March. All applicants will receive a decision and while we can only select a limited number of applicants for the first cycle, if you are not selected this year, please consider reapplying next year.

MiCHWA CHW Ambassador Program Application

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* 1. Contact Information

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

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* 3. Which of the following gender identities best describe you? (choose all that apply)

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* 4. Please list the language(s) in which you are proficient (read, write, and able to teach in)?

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* 5. MiCHWA hopes to find a wide variety of Ambassadors including an ambassador from each of our 10 regions. Using the picture below, please indicate which region you work in below.

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* 6. How many years of experience as a CHW do you have?

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* 7. Do you currently have an active MiCHWA Membership with access to the MiCHWA registry?

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* 8. Are you a MiCHWA Certified CHW?

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* 9. Are you a member of one (or more) of our workgroups?

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* 10. Have you ever been awarded a MiCHWA scholarship?

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* 11. What have you gained from being a member of the MiCHWA Registry?

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* 12. What have you learned from being a CHW?

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* 13. Why do you want to be a MiCHWA Ambassador?

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* 15. I certify that the information submitted in this application is true and correct to the best of my knowledge.I further understand that any false statements may result in the denial or revocation of this application.

* 15. I certify that the information submitted in this application is true and correct to the best of my knowledge.

I further understand that any false statements may result in the denial or revocation of this application.