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CHWAR Community Health Worker Student Training Application
Thank you for your interest in the Community Health Worker Association of Rochester (CHWAR) CHW Training program. We look forward to getting to know you.
1.
Please complete the following contact information:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Primary Phone:
Alternative Phone:
Email Address:
Emergency Contact Name:
Emergency Contact Phone #:
2.
What is the highest level of education you have completed?
Less than high school degree
High school degree or equivalent (i.e., GED)
Some college but no degree
Associates degree (2-year)
Bachelor's degree (4-year)
Graduate degree
Other (please specify)
3.
What is your age?
18-24
25-34
35-44
45-54
55-64
65 or over
4.
Are you of Hispanic, Latino, or of Spanish origin?
Yes
No
5.
How would you describe yourself?
American Indian or Alaskan Native
Asian or Asian American
Black or African American
Native Hawaiian or other Pacific Islander
White or Caucasian
Multiple ethnicity/Other (please specify)
6.
What is your level of English fluency?
Fluent English speaker
Limited English speaker
English is not my preferred language
7.
Do you speak any other languages?
Fluent speaker
Intermediate speaker
Do not speak
Spanish
Fluent speaker
Intermediate speaker
Do not speak
Other (please specify)
8.
What is your gender identity?
Man
Non-binary
Woman
Not specified above, please specify:
9.
Have you completed any type of CHW Training?
Yes
No
10.
Please list any other trainings or certifications you have taken:
11.
WORK EXPERIENCE (if yes, enter information below)
Yes
No
12.
Work Experience 1
Where:
Position Title:
Start Date of Employment:
End Date of Employment:
13.
Work Experience 2
Where:
Position Title:
Start Date of Employment:
End Date of Employment:
14.
Work Experience 3
Where:
Position Title:
Start Date of Employment:
End Date of Employment:
15.
Do you have experience with any of the following work fields? (Check all that apply)
Mental health
Chronic health conditions
Patient direct care services
Addiction/substance abuse
Prenatal care/children
Street outreach
COVID 19
16.
Please describe any special interests and/or other volunteer work experience:
17.
Why do you want to become a Community Health Worker?
18.
What experience do you have with advocating for patients/clients/family members with health related or other services?
19.
How did you hear about our CHW training?
