CH/AHEC CHW Apprenticeship Application

Community Health Worker Apprenticeship Application
(Partners) are looking for highly motivated, friendly, and passionate individuals that want to do more for their local community as a Community Health Worker Apprentice!

Community Health Workers (CHWs) are frontline public health workers who have a strong connection to their communities as trusted community members with a strong understanding of their communities culture, values, and needs.

Our CHW Apprenticeship program offers complete training and pairs candidates with community-based organizations to learn, perform, and grow as a valued CHW in the field!
Applicant Information

Tell us about yourself
Full Name*

First NameMiddle NameLast NameSuffix
Birthdate*

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Are you a citizen of the United States?*

YesNo
If no, are you authorized to work in the U.S.?

YesNo
Have you ever worked for this company?*

YesNo
If yes, when?
Have you ever been convicted of a felony?*

YesNo
If yes, explain?
Education
What is the highest degree or level of school you have completed? If currently enrolled, highest degree received.*

12th grade or lessHigh school diploma or GEDSome college, but no degreeAssociate degreeBachelor's degreePost-graduate degree
Previous Employment
Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job title
Starting Salary
Ending Salary
Responsibilities
From:
To:
Reason for leaving
May we contact your previous supervisor for a reference?

YesNo
Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job title
Starting Salary
Ending Salary
Responsibilities
From:
To:
Reason for leaving
May we contact your previous supervisor for a reference?

YesNo
Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job title
Starting Salary
Ending Salary
Responsibilities
From:
To:
Reason for leaving
May we contact your previous supervisor for a reference?

YesNo
Questions

Please answer the following questions in the text box below them
What does being a Community Health Worker (CHW) mean to you?*

0/500
How are you involved in your local community?*

0/500
Why do you feel you would be a good fit for the Community Health Worker Apprenticeship Program?*

0/500
What skills and experiences do you have that you feel make you a good candidate for this program?*

0/500
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature*

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Community Health Worker Apprenticeship Application

Applicant Information

Education

Previous Employment

Questions

Disclaimer and Signature