Temple University In-Person CHW Training Program - Interest Survey for 2026

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 initial on-line form and provide contact information. We will inform you about upcoming CHW training courses in 2024.

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1. Today's Date (Required.)

MM/DD/YYYY

Date

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2. Please provide contact information.

First Name

Last Name

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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3. In case of an emergency, please provide an emergency contact/

Name

Relationship to you

Phone Number

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4. What is your date of birth?

MM/YYYY

Date

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5. What is your gender?

Female

Male

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6. What are your preferred pronouns?

She/Her

He/Him

They/Them

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7. What is your race?

American Indian or Alaskan Native

Asian

Black or African-American

Native Hawaiian or other Pacific Islander

White

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

Hispanic or Latino

Non-Hispanic/Non-Latino

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9. Educational Attainment Level (check all that apply)

Less than High School

High School Diploma

GED

Vocational Training

Associate's Degree (2 year degree)

Bachelor's Degree (4 year degree)

Master's Degree

Doctorate/Professional

Other (please specify)

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10. Marital Status

Single

Living with Partner

Common Law

Married

Widowed

Separated

Divorced

Single Parent

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

1 person (myself only)

2 people

3 people

4 people

5 people

6 people

7 people

Other (please specify)

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12. How many dependents under 18 years of age do you have?

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13. How many of your children are under 5 years?

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14. What is your citizenship status?

US Citizen

Permanent Resident

Temporary Legal Status

Refugee

Non US Citizen

Asylum Seeker

Other (please specify)

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15. What is your country of origin?

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16. Please indicate if the following applies to you. If you check yes to any of the statements, we will provide you with additional information and support through the training program. (Please select all that apply.)

I am a U.S. Veteran.

I am enrolled in Medicaid (MA).

I have a disability.

I have a chronic health condition.

I have a past criminal conviction or offense.

I am bilingual.

I am currently attending school.

I have childcare issues.

I need help with obtaining a valid driver's license.

I am a PHA resident or receive a Housing Choice Voucher.

I have trouble meeting monthly expenses and would like to receive free confidential screening for benefit eligibility.

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* 1. Today's Date (Required.)

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* 2. Please provide contact information.

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* 3. In case of an emergency, please provide an emergency contact/

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* 4. What is your date of birth?

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* 5. What is your gender?

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* 6. What are your preferred pronouns?

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* 7. What is your race?

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

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

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* 10. Marital Status

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

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* 12. How many dependents under 18 years of age do you have?

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* 13. How many of your children are under 5 years?

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* 14. What is your citizenship status?

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* 15. What is your country of origin?

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* 16. Please indicate if the following applies to you. If you check yes to any of the statements, we will provide you with additional information and support through the training program. (Please select all that apply.)

1. Today's Date (Required.)

2. Please provide contact information.

3. In case of an emergency, please provide an emergency contact/

4. What is your date of birth?

5. What is your gender?

6. What are your preferred pronouns?

7. What is your race?

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

9. Educational Attainment Level (check all that apply)

10. Marital Status

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

12. How many dependents under 18 years of age do you have?

13. How many of your children are under 5 years?

14. What is your citizenship status?

15. What is your country of origin?

16. Please indicate if the following applies to you. If you check yes to any of the statements, we will provide you with additional information and support through the training program. (Please select all that apply.)