CHW Certificate Scholarship Application

Name(Required)

First Middle Initial Last

Home Address (Where checks will be mailed)(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

What year were you born?(Required)

What is your race? (select all that apply)(Required)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Decline to answer

What is your ethnicity?(Required)

Hispanic or Latino

Not Hispanic or Latino

Decline to answer

Other

What is your gender?(Required)

Are you currently employed?(Required)

What is your current job title?(Required)

Who is your employer?(Required)

What is your work address?(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How many hours a week do you work in your current job?(Required)

40 hours or more per week

30-40 hours per week

Less than 30 hours per week

Currently not working

Other

Do you need to get the CHW Certificate to keep your current job?(Required)

Yes

No

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Emergency Contact Email(Required)

Applying for classes starting in(Required)

August 2023 Start

August 2024 Start

January 2024 Start

What school do you plan to attend for your Certification?(Required)

Scholarship Application Questions

Please answer each question below in 250 words per question (1250 characters). You may type your answers into the boxes, or select to upload a PDF document.

Would you like to upload your responses as a document?(Required)

Yes

No

Upload Responses

Download this form to complete your answers. Upload it here when ready.

Upload Responses(Required)

Max. file size: 16 MB.

Questions

How would the CHW Certificate and/or this scholarship benefit you and/or your community?(Required)

CHWs are frontline public health workers who have a vital role to play in public health emergencies like COVID-19. How do you see yourself and other CHWs supporting communities in public health emergencies?(Required)

Please share a hardship or barrier in your past that you were able to overcome or tell us about a hardship or barrier in your life currently that this scholarship would help you overcome.(Required)

Is there anything else that you would like us to know about you?(Required)

Name

This field is for validation purposes and should be left unchanged.