APPLICATION

Provide a copy of your driver's license, high school diploma or GED, letter of recommendation and resume with application.
Program details at https://healthcareaccessnow.org/programs/community-health-worker-job-training/

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* 1. Select one session.

Days/Time: Mondays and Fridays, 9 a.m. to 5 p.m.

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* 2. How did you hear about the HCAN CHW Certification Training Program?

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* 3. Name

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* 4. Contact Information

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* 5. Personal Data

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* 6. Emergency Contact

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* 7. Academic Information

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* 8. Employment History - Current or Most Recent

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* 9. Employment History - Job 2

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* 10. Employment History - Job 3

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* 11. Employment History - Job 4

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* 12. Personal Statement
Why are you interested in going through this program and what are your expectations?
300 words or less

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* 13. THREE Professional/Personal References (cannot be family members)

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* 15. Upload copy of letter of recommendation.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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* 16. Let us know here if there is anything else you wish to share.

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* 17. Upload copy of your resume.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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* 18. Upload copy of other document.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File
You may wait until after review of your application to upload the following documents. These are required for certification by the Ohio Board of Nursing. 

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* 19. Upload copy of your high school transcript or copy of diploma, or GED.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 20. Upload copy of your driver's license.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File
Your application is complete upon receipt of the application fee. Check your email for the payment link, emailed in 1-2 business days, or return to the healthcareaccessnow.org webpage to pay now with a credit card online or with a cashier's or employer's check (personal checks not accepted).

When you click 'APPLY' your information will be submitted. Thank you!!

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