CHW Application (Stipend)
CHW Application (Stipend)
Name
Name
*
First
Last
Email
*
Phone
Phone
*
-
###
-
###
####
Address
Address
*
Street Address
City
State / Province / Region
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal / Zip Code
Country
United States
Gender
*
Female
Male
Transgender
Non-binary/Non-conforming
Prefer not to respond
Year of Birth
*
Maximum of
4
characters allowed.
Currently Entered:
0
characters.
Race
*
American Indian or Alaskan Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
*
Hispanic
Non-Hispanic
Highest Level of Education
*
Less than high school
High school diploma/GED
Some college
Associate's Degree
Bachelor's Degree
Post-graduate
Are you currently employed?
*
Yes
No
If yes, please list company name
Are you a Veteran?
*
Yes
No
Are you from a rural residential background?
*
Yes
No
Are you from a disadvantaged background?
*
Yes
No
An individual is considered to be from a disadvantaged background
if he or she meets
two or more
of the following criteria
:
Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act (Definition: https://nche.ed.gov/mckinney-vento/);
Were or currently are in the foster care system, as defined by the Administration for Children and Families (Definition: https://www.acf.hhs.gov/cb/focus-areas/foster-care);
Were eligible for the Federal Free and Reduced Lunch Program for two or more years (Definition: https://www.fns.usda.gov/school-meals/income-eligibility-guidelines);
Have/had no parents or legal guardians who completed a bachelor’s degree (see https://nces.ed.gov/pubs2018/2018009.pdf);
Were or currently are eligible for Federal Pell grants (Definition: https://www2.ed.gov/programs/fpg/eligibility.html);
Received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child (Definition: https://www.fns.usda.gov/wic/wic-eligibility-requirements).
Grew up in one of the following areas: a) a U.S. rural area, as designated by the Health Resources and Services Administration (HRSA) Rural Health Grants Eligibility Analyzer (https://data.hrsa.gov/tools/rural-health), or b) a Centers for Medicare and Medicaid Services-designated Low-Income and Health Professional Shortage Areas (qualifying zipcodes are included in the file). Only one of the two possibilities in #7 can be used as a criterion for the disadvantaged background definition.
Do you consent to a criminal background check?
*
Yes
No