March 2023 Community Health Worker Training

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:

• Fee

  Type	Fee
  Training Cost	$1,150.00
  Full Scholarship	No Charge

• Company:
• Job Title:
• City:
• State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• ZIP Code:
• * Phone:

How will you use this training?

• For reporting purposes, we are requesting the following information from you to inform our funders of how this training is impacting and being used in our communities:

• *

  Do you plan to seek employment in the Community Health Worker role in New Hampshire, i.e case manger, care coordinator, patient navigator, outreach worker, etc.?

  • Yes
  • No
  • Already employed as a CHW or similar role in N.H.
• * Which region of New Hampshire will you likely be working in as a Community Health Worker?
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• * How do you think becoming a trained Community Health Worker would help you achieve your personal, professional and/or community goals?
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• * How do you plan to use the skills that will be developed in this training?
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Electronic Acknowledgement & Signature

• Please review each item below to confirm your understanding of the requirements associated with participating in this training and/or receiving scholarship support. By placing your initials in each text box below this represents your electronic consent and signature for the acknowledgement of the terms of this training and/or scholarship support.

• Place your initials below confirming you are18 years of age or older.
• Place your initials below confirming that you will complete the course in full by attending all 9 sessions and completing all online requirements.
• Place your initials below confirming that in the event of your absence, you will make reasonable accommodations to make up the missing work/time.

• SCHOLARSHIP AGREEMENT: If you plan to participate in this training funded by a scholarship, you are agreeing that if you do not complete the training, you will not be eligible to receive another scholarship. You could take the training again at the full cost at a later date. You may be asked to reimburse NCHC the full or partial amount of tuition (up to $1150). **Exceptions may be made at the discretion of the training staff, based on circumstances and events beyond the control of the participant.

• SCHOLARSHIP PARTICIPANTS: Place your initials below confirming you are a resident of New Hampshire or work in New Hampshire.
• SCHOLARSHIP PARTICIPANTS: Place your initials below confirming that you have read and understand the expectations regarding acceptance of this scholarship.
• SCHOLARSHIP PARTICIPANTS: Place your initials below confirming that you will join the NH CHW Coalition as a member by visiting NCHCNH.org.

Mailing Address:

• Please provide a mailing address where you can receive a box of course materials:

• Mailing Address for course materials: