Leadership Institute: 2025 Southwest Region Application < Back to Leadership Institute Home Page Leadership Institute Application Name(Required) First Last Resume(Required)Please upload a copy of your resumeMax. file size: 50 MB.Home Address(Required) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 What is your ethnicity?(Required) Hispanic or Latino Not Hispanic or Latino What is your gender?(Required) Man Woman Non-binary Transgender Please list any languages that you speak or read other than English (if you only read and speak English, write 'none').(Required)Veteran Status(Required) Not a Veteran National Guard Reservist Veteran- Prior Service Veteran- Retired What year did you start your career as a CHW?(Required)Are you a Minnesota Community Health Worker Certificate holder?(Required) Yes No I am currently enrolled in a CHW Certificate program Other What year did you recieve your CHW Certificate?(Required)What school did you attend to get your certificate?(Required) Minnesota West Community and Technical College Northwest Technical College Normandale Community and Technical College St. Catherines University Saint Mary’s University of Minnesota Other Employment status(Required) Employed in a CHW role Employed in a role similar to a CHW Employed in a role that is unrelated to the CHW role Not currently employed Other Who is your employer?(Required)What is your job title(Required)County or Tribal Nation of employer(Required)UnsureBois 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 MedicineSupervisor Name(Required) First Last Supervisor Job Title and credentials (i.e. CHW, MPH, RN etc.)(Required)Supervisor Email(Required) Please upload a letter of recommendation from you supervisor(Required)Max. file size: 50 MB.How many hours a week do you work as a CHW?(Required) 40 hours or more per week 30-40 hours per week Less than 30 hours per week Currently not working as a CHW Other Are there any special needs or accommodations that would make is easier for you to participate in the Leadership Institue?(Required)Please select all dates that you are ABLE to participate in the Southwest Leadership Insitute in-person in Worthington MN:(Required) February 18 2025 March 18 2025 April 15 2025 May 20 2025 June 17 2025 July 15 2025 Select AllApplication QuestionsPlease answer each question below in 250 words per question (1250 characters max). You may type your answers into the boxes.Why have you become a CHW?(Required)Why are you interested in participating in the CHW Leadership Institute?(Required)How do you hope to grow and benefit from the program? What are your thoughts on how you would like to put your leadership skills to use?(Required)Briefly highlight any community and volunteer involvement including any past or current leadership roles (e.g. school, cultural group, neighborhood, faith-based group)(Required)Briefly list how you are involved in the CHW field (such as the work of the MN CHW Alliance, attending educational programs of the MN CHW Peer Network, etc).(Required)Briefly, in a few sentences, what else would you like us to consider in the evaluation of your application?(Required)Consent(Required)I understand that the MN CHW Alliance may select only a specific number of participants. If I am selected, I agree to the following: 1. I will actively participate in the CHW Leadership Program including all sessions and required activities/assignments including a brief program evaluation. 2. I understand that I must attend all sessions in order to receive a Certificate of Completion. 3. Building on my leadership skills. I am committed to stepping into future leadership and representational roles as a CHW. 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 Minnesota Department of Health (MDH) for the purposes of grant reporting. I agreeNameThis field is for validation purposes and should be left unchanged. Δ
