Register as a CHW Please complete this entire form to the best of your ability to join and gain access to the Minnesota Community Health Worker Alliance Registry as a CHW.First Name* Last Name* Email Address* Home County or Tribal Nation of Residence*Not a MN ResidentBois Forte Band of ChippewaFond du Lac Band of Lake Superior ChippewaGrand Portage Band of Lake Superior ChippewaLeech Lake Band of OjibweLower Sioux Indian CommunityMille Lacs and of OjibwePrairie Island Indian CommunityRed Lake NationShakopee Mdewakanton Sioux CommunityUpper Sioux CommunityWhite Earth NationAitkinAnokaBeckerBeltramiBentonBig StoneBlue EarthBrownCarltonCarverCassChippewaChisagoClayClearwaterCookCottonwoodCrow WingDakotaDodgeDouglasFaribaultFillmoreFreebornGoodhueGrantHennepinHoustonHubbardIsantiItascaJacksonKanabecKandiyohiKittsonKoochichingLac Qui ParleLakeLake Of The WoodsLe SueurLincolnLyonMahnomenMarshallMartinMcLeodMeekerMille LacsMorrisonMowerMurrayNicolletNoblesNormanOlmstedOtter TailPenningtonPinePipestonePolkPopeRamseyRed LakeRedwoodRenvilleRiceRockRoseauSaint LouisScottSherburneSibleyStearnsSteeleStevensSwiftToddTraverseWabashaWadenaWasecaWashingtonWatonwanWilkinWinonaWrightYellow Medicinei.e. Hennepin, Dakota, Upper Sioux CommunityHome Zipcode* Gender*MaleFemaleTransgenderNon-BinaryOtherPrefer to not disclosePronouns*she/herhe/himthey/themzie/zerotherRace/Ethnicity*American Indian or Alaska NativeEast Asian (i.e. Chinese, Asian Indian, Korean, Japanese, etc.)South Asian (i.e. Indian, Nepalese, Afghan, Pakistani, Bangladesh, Bhutanese, Maldivian, Sri Lankan, etc.)Other AsianBlack, African, or African AmericanHispanic, Latino, or Latino originMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhiteOther racePrefer not to answerAffiliation with any specific community (ex: ethnic, refugee, disability, rural, LGBTQIA)? I verify that I am a community health worker.*YesNoAre you a Minnesota CHW Certificate holder?*YesNoUnsureWhat school issued your certificate? What year did you earn your certificate? Use of Model In Work ImplementationPathwaysHome HealthcareImpactOtherDescribe the setting and functions you carry out regularly: Years of experience working as a CHW0-11 Months1-2 Years2-3 years3-5 years5+ years10+ yearsWhat language(s) are you proficient in?* Are you fluent in American Sign Language (ASL)?YesNoIf yes, are you registered as an ASL interpreter?YesNoEmployer Name* Employer Zip Code* Employer County*Not a MN ResidentBois Forte Band of ChippewaFond du Lac Band of Lake Superior ChippewaGrand Portage Band of Lake Superior ChippewaLeech Lake Band of OjibweLower Sioux Indian CommunityMille Lacs and of OjibwePrairie Island Indian CommunityRed Lake NationShakopee Mdewakanton Sioux CommunityUpper Sioux CommunityWhite Earth NationAitkinAnokaBeckerBeltramiBentonBig StoneBlue EarthBrownCarltonCarverCassChippewaChisagoClayClearwaterCookCottonwoodCrow WingDakotaDodgeDouglasFaribaultFillmoreFreebornGoodhueGrantHennepinHoustonHubbardIsantiItascaJacksonKanabecKandiyohiKittsonKoochichingLac Qui ParleLakeLake Of The WoodsLe SueurLincolnLyonMahnomenMarshallMartinMcLeodMeekerMille LacsMorrisonMowerMurrayNicolletNoblesNormanOlmstedOtter TailPenningtonPinePipestonePolkPopeRamseyRed LakeRedwoodRenvilleRiceRockRoseauSaint LouisScottSherburneSibleyStearnsSteeleStevensSwiftToddTraverseWabashaWadenaWasecaWashingtonWatonwanWilkinWinonaWrightYellow Medicinei.e. Hennepin, Dakota, Upper Sioux CommunityHow do you best describe your current CHW employer?*Community clinicCommunity-based organizationEducational institutionFaith-based organizationFor-profit organizationHospital/health systemLocal public health agencyManaged care organizationMedical clinicMental health providerOral health providerSocial services agencyState agencySubstance use organizationOtherIf other, please provide a brief description: Any Support Needed?Hiring Support (Job Descriptions, Data Tracking, Policies)Job OpeningsOngoing TrainingOrganizational ReadinessI'm interested in:ApprenticeshipsCHW Learning CircleCHW Leadership InstituteLegislative AdvocacyMNCHWA Monthly NewsletterOrganizational Readiness SupportScholarshipsOtherIf other, please provide a brief description: Create your username and password below. This login information will allow you to access your profile, additional resources on the MNCHWA website, and the CHW Directory after you purchase your Annual Registry Membership (Those with a promo code, will enter their discount code in the checkout page).Username* Password* Confirm Password*Note: Profile Info can be edited/updated after registration. The MN CHW Registry is intended to help grow and strengthen the CHW field in Minnesota in order to advance health equity. The Registry reflects the nonprofit mission of the Minnesota CHW Alliance to build community and systems capacity for better health through the integration of CHW strategies. Based on CHW input, the Alliance has established data privacy and security safeguards. The Alliance will protect the privacy of individual data furnished to the registry. Any reports that the Alliance prepares on the CHW workforce will be based on aggregated registry data that does not identify individuals. Names and contact information will not be shared with any third party without advance written permission. Data will be used solely for purposes that relate to the CHW field. Show privacy policy Please confirm that you agree to our privacy policy Only fill in if you are not human Login