CHW Registration Form – Personal Development CHW Registration Form CHW Self Pay Training Form Date PERSONAL INFORMATION First/ Middle Name * Print First | M | Last Name (As it should appear on a certificate) Last Name * Date of Birth * Sex * MaleFemalePrefer not to identify LOCATION INFORMATION Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal CONTACT INFORMATION Email * Phone TRAINING INFORMATION Training Sponsored By * MDH - Maryland Department of Health - (Community Health Worker Training)CHISS - (Community Health Worker and COVID 19 TrainingSODH - Social Determinants of HealthTraining Not Sponsored I am a Resident of: * Allegany CountyAnne Arundel CountyBaltimore CityBaltimore CountyCalvert CountyCaroline CountyCarroll CountyCecil CountyCharles CountyDorchester CountyFrederick CountyGarrett CountyHarford CountyHoward CountyKent CountyMontgomery CountyPrince George's CountySomerset CountySt. Mary's CountyTalbot CountyWashington CountyWicomico CountyOther I am a Resident of: Are you Certified? * Yes No If you are not a Certified Community Health Worker CHW Training Summer 2022 CHW Training Fall 2022 CHW Training Winter 2023 CHW Training Spring 2023 State * License Number * Advanced CHW Training ACCEPTANCE AND COMMITMENT TRAINING Part IACCEPTANCE AND COMMITMENT TRAINING Part IIIF YOU ARE REGISTERING FOR Part I and IICOVID-19- INFECTIOUS DISEASE TRAINING- 12- HOURWOMEN’S HEALTH and WELLNESS REFERENCE LETTER QUALIFICATIONS:(one from general reference and one from current or previous employer)A. Two (2) letters of recommendation to include applicant’s academic aptitude, ability to work with others, capacity for self-development, dependability and any other helpful details to allow us to assess the applicant’s position in the field of Community Health Workers. B. Proof You've Received:1. GED2. High School Diploma Upload Documentation Here: Drop a file here or click to upload Choose File Maximum file size: 516MB SIGNATURE/AGREEMENT I certify that the information recorded on this application is correct and if the information changes, will provide a timely update. I agree Signature * Clear Date * If you are human, leave this field blank. Submit
CHW Registration Form
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