MiCHWA CHW Training Registration Form

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* 1. Please tell us who you are.

Name

Agency

Title

Email Address

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* 2. Why are you interested in participating in this course?

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* 3. How long have you worked as a CHW?

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* 4. If currently employed and seeking to participate in the class during working hours, please acknowledge the support of your supervisor.

Yes

No

N/A

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* 5. Please provide your Supervisor's contact information below. Skip this question if you answered "N/A" above.

Name

Email

Phone Number

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* 6. I agree to participate and engage for the full duration of the course. I understand that failure to complete all 126 hours will result in a drop from the class as well as no certification will be received.

Yes

No

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* 7. I attest that myself or my organization will be able to pay the $1,000 fee to participate in this course. This includes the course book fee and the first year of the MiCHWA CHW registry access.

Yes

No

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* 8. Please provide the contact information for those who should receive the invoice to cover the course fees.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number