Community Health Worker Training - Enrollment Form

Pharmacy-Based Community Health Worker Training

CERTIFICATE PROGRAM ENROLLMENT
The Pharmacy-Based Community Health Worker Certificate Program is a 14-week program.

Content will be delivered in a combination of online, on-demand learning, 3 live webinars, and 2 days of in-person learning.

Live, virtual webinars will be held via Zoom on August 5, September 30, and November 4 from 6pm-8pm CT.

The live, in-person program will be held on Monday, October 20th (8am-5pm CT) and Tuesday, October 21st (8am-12pm CT) in New Orleans, LA.

Complete the following form to enroll in the Pharmacy-Based Community Health Worker Certificate Program.
Confirm the session to get started:*

August 5, 2025 - November 4, 2025

Commitment to Participate
National Community Pharmacists Association (NCPA) is providing scholarship funding (valued at $1500) to technicians committed to participating in and completing Pharmacy-Based Community Health Worker Training.

The following list includes all requirements for participation in the training course:
- Submit an active email address for a Dedicated Supporter (pharmacist, pharmacy manager, or owner) who will engage with the CHW candidate and provide resources and support for the candidate for the entire length of the program, including any post-reporting or inquiries from program administrators. Dedicated Supporters will be emailed a letter indicating they have been identified as such.
- Commit to completing all course requirements:
  - Complete all reading and assignments. Anticipate 2-3 hours of homework per week, including course readings, outside of regular class time.
  - Complete 60 hours of resource development activities outside of regular class time.
    
    Please note, each individual learner (in collaboration with their practice site and Dedicated Supporter) is responsible for identifying their resource development opportunities and coordinating all associated logistics. Course facilitators and instructors will provide guidance for identifying resource development opportunities, but learners are ultimately responsible for executing all tasks associated with resource development.
  - Document a minimum of 30 Resources and create a Resource Portfolio to support future work as a CHW.
    
    Please note, guidance for creating a Resource Portfolio will be provided as part of the course.
  - Obtain 2 CHW Core Competency Assessments from points of contact outside the pharmacy.
- Commit to attending all live webinars and the in-person program.
  - Attendance at live webinars and the in-person program is REQUIRED.
- Provide any required contact and demographic information.
- Agree to receive program emails, texts, and other communications to ensure ongoing engagement with the program to assist in continuous improvement of the program and amplification of the impact that the program has in local communities.
- Participate in ongoing reporting of outcomes and benefits.
- Have access to a computer, tablet, or other device with a camera, microphone, speakers, and internet access to facilitate active engagement during live sessions.

Course Requirements
To meet the requirements of this course, I agree to:
- Actively participate in course discussions and activities.
- Attend all live webinars and the in-person program
  - Attendance at webinars and the in-person program is REQUIRED for partipation in Community Health Worker training.
- Complete all course work and activities as assigned (anticipate 2-3 hours of homework per week, including course readings).
- Complete 60 hours of resource development activities outside of regular class time.
  - Please note, each individual learner (in collaboration with their practice site and dedicated supporter) is responsible for identifying their resource development opportunities and coordinating all associated logistics. Course facilitators and instructors will provide guidance for identifying resource development opportunities, but learners are ultimately responsible for executing all tasks associated with resource development.
- Create a Resource Portfolio including a minimum of 30 Resources to support my future work as a CHW.
  - Please note, guidance for creating a Resource Portfolio will be provided as part of the course.
- Obtain 2 CHW Core Competency Assessments from points of contact outside the pharmacy.
State Certification Attestation
State Certification Attestation*

Registrant Information

Enter your contact information below.
Name*

First NameLast Name
Email*
Please enter a valid email address. This email address will be used for all course communications.
Personal Mobile Phone*
Please enter a valid phone number. We will not share this number. It will be used solely for the purpose of communication related to this course.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Live, In-Person Program
A live, in-person program will be held Saturday, November 18th (8am-5pm) - Sunday, November 19th (8am-12pm at various locations:
1. University of Missouri School of Pharmacy – Kansas City Campus
  2464 Charlotte St., Kansas City, MO 64108
2. University of Missouri School of Pharmacy – Springfield Campus
  327 W Mill St., Springfield, MO 65806
3. University of Health Sciences & Pharmacy
  1 Pharmacy Place, St. Louis, MO 63110
4. Louisville, KY (exact location TBD)
5. New York, NY (exact location TBD)
Select your preferred location for the live, in-person program:*

University of Missouri School of Pharmacy – Kansas City Campus (Kansas City, MO)University of Missouri School of Pharmacy – Springfield Campus (Springfield, MO)University of Health Sciences & Pharmacy (St. Louis, MO)Louisville, KY (exact location TBD)New York City, NY (exact location TBD)
Personal Statement
Please provide a brief, personal statement about why you want to complete the CHW training. How will you use this training in your community? Please provide 3-5 sentences below.*

Employer's Information

Enter your employer's information below.
Name of Pharmacy or Company*
Employer's NCPDP Provider Identification Numbers (primary practice site)
What is an NCPDP Provider ID Number? The NCPDP Provider ID is a seven-digit numbering system that is assigned to every licensed pharmacy and qualified non-pharmacy dispensing sites (NDPS) in the U.S.
Employer's Street Address (primary practice site)*
City*
State*
Zip Code*
Employer's Phone Number*
Please enter a valid phone number.

Required Materials
The following materials/equipment are required for this course:
- Computer, tablet, or other mobile device, capable of supporting online meeting on Zoom^(R)
- Camera, microphone, and speakers (either build into the device or as external auxiliary equipment)
- Reliable (preferably high-speed) internet access

Required Textbook
The following textbook is required for this course:

Foundations for Community Health Workers; Second Edition (2016), Jossey-Bass Publications; John Wiley and Sons, Inc.

The textbook is available from:
- Publisher
- Amazon
- Have CEimpact purchase an electronic version of the textbook for you and email it to you ($100 fee)
- Have CEimpact purchase a physical copy of the textbook and ship it to you ($125 fee)
Textbook Details
The following textbook is required for this course:

Foundations for Community Health Workers; Second Edition (2016), Jossey-Bass Publications; John Wiley and Sons, Inc.

An electronic copy of the textbook is included in the course. Textbooks will be ordered AFTER the first live class meeting.
Please select your preferred type of textbook:*

Electronic Format (readable through the Kindle app on your computer or mobile device)Printed Format (a paperback printed book)
Please enter the email where your electronic textbook should be delivered:*
example@example.com
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.

Scholarship Details
Congratulations! Because your organization is located in Missouri, you are eligible for a full-tuition scholarship from the Missouri Pharmacy Association (a $1,380 value)!

To meet the requirements of the CHW scholarship, I agree to:
- Actively participate in virtual classroom discussions and activities.
- Complete all course work and activities as assigned (anticipate 2-3 hours of homework per week, including course readings).
- Complete 60 hours of service-learning activities outside of regular class time and create a Resource Guide to support my future work as a CHW. Guidance for identifying service-learning opportunities and creating a Resource Guide will be provided as part of the course.
Please confirm your acceptance of the scholarship terms above:*

Yes! I accept the terms of my scholarship and look forward to getting started!
Select your textbook preference:*

Electronic format - readable through the Kindle app on your computer or mobile devicePrinted format - a paperback printed book
You will receive an email from CEimpact within 3 business days confirming your scholarship and providing instructions for next steps.
Cart

If you have a scholarship code, please enter it in the coupon box below.
Textbook Details
If you selected an electronic textbook, what is the email where it should be sent?
example@example.com
If you selected a printed copy of the textbook, what is the address where it should be sent?

Home addressCompany addressNot applicable - I chose an electronic copy of the textbook or I will be purchasing the textbook myself
Click submit to complete your enrollment.
Questions? Email us at CHW@ceimpact.com.
Should be Empty:

Pharmacy-Based Community Health Worker Training

Commitment to Participate

Course Requirements

State Certification Attestation

Registrant Information

Live, In-Person Program

Personal Statement

Employer's Information

Dedicated Supporter

Required Materials

Required Textbook

Textbook Details

Scholarship Details

Cart

Textbook Details