Community Health Worker Online Certification Program

APPLICATION

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

- Program details at https://www.healthcareaccessnow.org/certification-and-education/certification-program/

- 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.

*1.Personal Information(Required.)

Full Name

Preferred Name (if different)

Email Address

Phone Number

Mailing Address

City, State, Zip Code

County of Residence

Date of Birth

Last 4 digits of SSN

Demographics

*2.What is your gender identity?(Required.)

Female

Male

Non-binary

Transgender

Prefer not to answer

Prefer to self-describe:

*3.What is your Race/Ethnicity (Select all that apply)(Required.)

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino/a/e

Middle Eastern or North African (MENA)

Native Hawaiian or Other Pacific Islander

White

Another Race/Ethnicity (Please Specify):

*4.What language(s) do you speak or prefer for communication(Required.)

English

Spanish

Arabic

French

Somali

Other (please specify)

*5.Are you a U.S. Military Veteran?(Required.)

Yes

Prefer not to answer

*6.Do you identify as a person with a disability?(Required.)

Yes

Prefer not to answer

*7.Emergency Contact(Required.)

Full Name

Phone Number

Relationship

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