Register as a CHW NEW CHW REGISTRATION FORMΔPlease 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 NameLast NameEmailHome County or Tribal Nation of Residencei.e. Hennepin, Dakota, Upper Sioux CommunityNot 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 MedicineHome Zip CodeZIP / Postal CodeGenderFemaleMaleNon-binaryAgenderTransgenderMy gender is not listedPrefer not to answerPronounsshe/hershe/theyhe/himhe/theythey/themzie/zerotherRace/Ethnicity American Indian or Alaska Native East Asian (i.e. Chinese, Asian Indian, Korean, Japanese, etc.) South Asian (i.e. Indian, Nepalese, Afghan, Pakistani, Bangladesh, Bhutanese, Maldivian, Sri Lankan, etc.) Other Asian Black, African, or African American Hispanic, Latino, or Latino origin Middle Eastern or North African Native Hawaiian or Pacific Islander White Other race Prefer not to answerIf other, please enter details here:Affiliation with any specific community (ex: ethnic, refugee, disability, rural, LGBTQIA)?I verify that I am a community health worker. Yes NoAre you a Minnesota CHW Certificate holder? Yes No UnsureWhat school issued your certificate?What year did you earn your certificate?Use of Model In Work Implementation Pathways Home Healthcare Impact OtherIf other, please enter details here: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)? Yes NoIf yes, are you registered as an ASL interpreter? Yes NoEmployer NameEmployer Zip CodeZIP / Postal CodeEmployer Countyi.e. Hennepin, Dakota, Upper Sioux CommunityNot 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 MedicineHow do you best describe your current CHW employer? Community clinic Community-based organization Educational institution Faith-based organization For-profit organization Hospital/health system Local public health agency Managed care organization Medical clinic Mental health provider Oral health provider Social services agency State agency Substance use organization OtherIf other, please provide a brief description:Any Support Needed?– Select –Hiring Support (Job Descriptions, Data Tracking, Policies)Job OpeningsOngoing TrainingOrganizational ReadinessI’m interested in:– Select –ApprenticeshipsCHW Learning CircleCHW Leadership InstituteLegislative AdvocacyMNCHWA Monthly NewsletterOrganizational Readiness SupportScholarshipsOtherIf other, please provide a brief description:Create your username and password in the next fields. 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).UsernamePasswordNote: 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. Submit
