CHW Upskilling Application

Name Name First Last
Email
Phone Phone - ### - ### ####
Address Address
Street Address City State / Province / Region Postal / Zip Code Country
Gender
Year of Birth
Maximum of 4 characters allowed. Currently Entered: 0 characters.
Race
Ethnicity
Highest Level of Education
Are you currently certified by Texas Department of State Health Services as a Community Health Worker or other Health Support Worker (i.e.; health care aids, peer support specialists, health education specialists, doulas, etc.)
Please enter your certificate/license number
Are you currently employed?
If yes, please list company name
Estimated number of clients served per month
Please select what underserved areas you are currently involved in. Check all that apply

Please select what underserved areas you are currently involved in. Check all that apply Federally Qualified Health Center Health Department Community Health Center Community Action: Health, Head Start, Childcare, Workforce, Community and Transportation Mental Health Authority/Behavioral Health Special Populations: Homeless, Migrants and Public Housing Prenatal/Women's Health Rural Health Clinic Indian Health Center Health professionals shortage area No previous experience Other Other
Are you a Veteran?
Are you from a rural residential background?
Are you from a disadvantaged background?
An individual is considered to be from a disadvantaged background if he or she meets two or more of the following criteria:
1. Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act (Definition: https://nche.ed.gov/mckinney-vento/);
2. 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);
3. 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);
4. Have/had no parents or legal guardians who completed a bachelor’s degree (see https://nces.ed.gov/pubs2018/2018009.pdf);
5. Were or currently are eligible for Federal Pell grants (Definition: https://www2.ed.gov/programs/fpg/eligibility.html);
6. 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).
7. 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 agree to complete the 50-hour upskilling course within ninety (90) days?
Do you agree to attend new student orientation via Zoom on September 23, 2024 at 5:30 pm CST?
Do you agree to attend Mental Health First Aid via Zoom on one of the following dates, Friday November 15, 2024, 9 am – 4 pm CST -OR- Saturday, December 7, 2024, 9 am – 4 pm CST?
Please describe how you plan to include the knowledge gained from this course into your current work.
Maximum of 1000 characters allowed. Currently Entered: 0 characters.
Only those with complete submissions will be considered.

Those accepted into the program will be notified via email and must attend new student orientation on September 23, 2024 at 5:30 pm CST and one of the scheduled MHFA trainings, both via Zoom.

CHW Upskilling Application

CHW Upskilling Application

An individual is considered to be from a disadvantaged background if he or she meets two or more of the following criteria:

Only those with complete submissions will be considered.