CHW Application (Apprentice)

Page 1 of 2 - Demographic

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Name Name * First Last
Email *
Phone Phone * - ### - ### ####
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Have you ever been certified as a Community Health Worker or other Health Support Worker (i.e.; health care aids, peer support specialists, health education specialists, doulas, etc.) *

Have you ever been certified as a Community Health Worker or other Health Support Worker (i.e.; health care aids, peer support specialists, health education specialists, doulas, etc.) Yes No
Do you consent to a criminal background check? *

Do you consent to a criminal background check? Yes No
Do you consent to a drug screen? *

Do you consent to a drug screen? Yes No
Are you able to commit to a minimum of 2000 hours of training
(40 hours per week for one year)? *

Are you able to commit to a minimum of 2000 hours of training
(40 hours per week for one year)? Yes No