Community Health Worker Training – Registration CHW Training Registration Today's Date: MM slash DD slash YYYY (Check one): Initial Certification Training Continuing Education (CEU) CEU Class Title: Date of Class: MM slash DD slash YYYY Student Name:* First Last Street Address: City/ State: Zip code: Phone:Email:* Gender: Male Female Date of Birth (MM/DD/YYYY): MM slash DD slash YYYY Ethnicity (select one): Hispanic Non-Hispanic RACE (select all that apply): African American/Black American Indian/Alaskan Native Asian Native Hawaiian/Another Pacific Islander White Highest level of education earned: Are you fluent in other Languages? (Please specify)1. Speak Read Write 2. Speak Read Write Please provide a personal statement of why you are interested in becoming a CHW (Initial Certification Only):Please provide a personal statement of why you are interested in becoming a CHW (Initial Certification Only):Media ConsentPlease download the Media Consent Form, sign and scan (or take a photo) and upload the signed photocopy of the form. (You may also email the consent form to *protected email*)Signed consent file to uploadAccepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.Thank you for your interest. We will contact you shortly.CAPTCHA