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MiCHWA CHW Training Registration Form
1.
Please tell us who you are.
Name
Agency
Title
Email Address
2.
Why are you interested in participating in this course?
3.
How long have you worked as a CHW?
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
5.
Please provide your Supervisor's contact information below. Skip this question if you answered "N/A" above.
Name
Email
Phone Number
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
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
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
