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 Current Professional Role:* 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): (required)*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