Community Health Worker Career Pathways Program

Program Application and Eligibility Form

Thank you for your interest in the Community Health Worker Training Program. Please complete this on-line application and eligibility form. We will contact you regarding coming to Temple University Harrisburg for an information session.

* 1. Today's Date


* 2. Please provide contact information.

* 3. What is your date of birth?


* 4. What is your gender?

* 5. What is your race?

* 6. What is your ethnicity? (Please select all that apply.)

* 7. Please indicate if you identify with any of the following categories. (Please select all that apply.)

* 8. Please indicate if the following applies to you. (Please select all that apply.)

* 9. What are your goals after completion of the CHW Training Program? (Check all that apply.)

* 10. How many people currently live in your household, including yourself?

* 11. Marital Status

* 12. Educational Attainment Level (check all that apply)