UniteWI Workforce Training Question Title * 1. Name (first and last) Question Title * 2. Address Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 3. What race/ethnicity best describes you? (Please only choose one). American Indian or Alaskan Native Asian/Pacific Island Black or African American Hispanic White/Caucasian Other (please specify) Question Title * 4. Date of Birth Date / Time Date Question Title * 5. What training would you like to attend? CHW Training Cohort 1: Time: 8am-4pm; Dates: Week 1: February 2-6, 2026; Week 2: February 23-27, 2026 CHW Training Cohort 2: Times: 12pm-4pm; Dates: April 27, 2026-May 22, 2026 CHW Training Cohort 3: Times: 12pm-4pm; Dates: September 14, 2026-October 9, 2026 CHW Supervisor Training : Wednesdays 12pm-4pm; January 28, 2026-March 4, 2026 Question Title * 6. Will you be receiving financial assistance from Maximus/EquusWorks/AmericaWorks? Yes No Question Title * 7. If no to the above question, how will the training be paid? Question Title * 8. Are you currently working with an Agency? Please list the Agency below. Question Title * 9. If you are working with Agency. Please list your Supervisor name? Question Title * 10. Supervisor email Question Title * 11. Supervisor Phone Number Question Title * 12. Preferred Pronouns Question Title * 13. Highest Level of Education Received High School K-12 but did not graduate Junior College or Technical Degree Some College College/University Degree Advanced Degree (Master or Doctorate) Question Title * 14. Veteran Status National Guard Active-Duty Military Veteran-Prior Service Not Applicable Question Title * 15. What are your plans after your CHW training is completed? Question Title * 16. Do you now or have you ever lived in a rural area? Yes No Question Title * 17. Do you identify as being from a disadvantaged background? Yes No Done
