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.

Today's Date

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* 1. Today's Date

MM/DD/YYYY
Please provide contact information.

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* 2. Please provide contact information.

What is your date of birth?

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* 3. What is your date of birth?

MM/YYYY
What is your gender?

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* 4. What is your gender?

What is your race?

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* 5. What is your race?

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

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

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

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

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

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

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

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

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

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

Marital Status

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* 11. Marital Status

Educational Attainment Level (check all that apply)

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

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