CHWTP Forms Student Re-enrollment Request Form Name(Required) First Last Email(Required) What is the main reason that you were unable to complete the CHW Certificate course?(Required) Financial stressors Program was not was you expected Time commitment Workload Online learning platform (D2L) Personal or family reasons Language barriers Internship expectations Concern about job opportunities for CHWs Other What kind of support would have made it easier for you to continue in the CHW Certificate program?(Required) School based support Technology support Peer to peer support Mentotorship support More knowledge about the CHW profession Support with internship course component None of these, I had to withdraw for personal reasons Other How confident are you that you would be successful in completing your CHW Certificate if you re-enroll?(Required) Very Confident Somewhat Confident Neutral/unsure Not at all confident Other Please describe any changes that have occurred since you withdrew from your CHW Certificate classes that will make you more likely to be successful if you re-enroll. You may say 'not applicable' if the reason for your withdrawal is a one time family or personal issue.(Required)What steps have you taken to recoup funds from your school?(Required) Filed a Refund Petition Form Contacted school Administration Both of these none of these Other Please upload any forms you have completed in an effort to recoup fundsMax. file size: 50 MB.What additional funding sources have you secured to pay for the remainder of your CHW Certificate?(Required) Financial aid Other scholarships or grants Employer none needed, my school accepted my withdrawal refund petition Other Please upload any documentation of secured funding sourcesMax. file size: 50 MB.Who is your current employer?(Required) May MNCHWA contact your employer?(Required) Yes No Employer contact: please provide name, title and email or phone number(Required) What school did you withdraw from?(Required) Minnesota West Community and Technical College Normandale Community College Northwest Technical College St. Catherine’s University St. Mary’s University What school do you plan to enroll in?(Required) Minnesota West Community and Technical College Normandale Community College Northwest Technical College St. Catherine’s University St. Mary’s University Consent(Required)By checking this box, I give permission to the Minnesota Community Health Worker Alliance to share the information in this form with the accredited schools listed above for the purposes of determining eligibility for this scholarship, verifying acceptance in the CHW program at your chosen school and completing the invoicing process to apply your scholarship to your student account at your chosen school. I agreeConsent(Required)By checking this box, I give permission to the Minnesota Community Health Worker Alliance to share de-identified information in this form with the Minnestoa Department of Health (MDH) and the Health Resources and Services Administration (HRSA) for the purposes of grant reporting. I agree PhoneThis field is for validation purposes and should be left unchanged. Δ
