Clone of Futures First: Program Interest

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Welcome to FUTURES FIRST Community Health Worker Program!

The Community Health Worker (CHW) Program is an education and career pathway for individuals interested in working in community-based health, outreach, and support roles.

Through this program, selected participants will have the opportunity to complete a free 152-hour Community Health Worker training course offered in collaboration with California State University, Dominguez Hills (CSUDH). Due to limited enrollment, participation is based on interest, readiness, and alignment with the role of a CHW.

This short form helps us learn more about you, your interests, and your goals related to pursuing a career as a Community Health Worker. Your responses will help our team determine whether this training opportunity is a good fit for you.

What happens next?

A Case Manager or program staff member will review your responses
Selected applicants will be contacted to schedule a follow-up conversation
If you are a good fit, you will receive next steps related to enrollment, course expectations, and orientation
Submitting this form does not guarantee placement, but it is the first step in being considered for the CHW training opportunity.

Thank you for your interest in becoming a Community Health Worker and for taking the time to share more about yourself.

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Name* This field is required.

First Name

Last Name

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E-mail

example@example.com

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Phone Number* This field is required.

Area Code

Phone Number

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Date of Birth* This field is required.

Date

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Are you between the ages of 18 and 26 years old

Yes

No

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What is your age?

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What is your gender identity* This field is required.

Male

Female

Non-Binary

Other

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Are you currently attending high school or college/university?

Yes

No

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What is your highest level of education completed?

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Are you familiar with the role of a Community Health Worker?

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Are you currently working?

No

Yes, Full Time

Yes, Part-Time

Yes, Paid Internship

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Were you, are you, or will you be the first person in your immediately family to attend college or health career technical school?

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Are you currently working Part time (20 hours or less)?

Yes

No

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Class RequirementsPlease Check all that apply

Do you have access to a laptop?

Do you have Internet access at home?

Are you able to attend in person classes at California State University Dominquez Hills?

Are you able to attend virtual classes?

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NEXT STEPS

Next steps in the process involve our team reaching out to you in order to schedule a brief meeting. We understand that your schedule may be busy, so we will work with you to find a suitable time for these meetings, which typically occur on a weekly basis.

You would also be invited to attend our "Learn more about CHW" program. A virtual self-paced training that gives yout an introduction into CHW. You will have the opportunity to learn more about the Futures First CHW Program, its objectives, and the specific benefits it offers. This is your chance to gain a deeper understanding of how the program can support your personal and career development goals.

If, after learning about the program, you find it interesting and meet the eligibility criteria, you will be enrolled into the Futures First CHW Program. We are excited to embark on this journey with you and look forward to assisting you in reaching your educational and career aspirations.

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is Participant Eligible ?

YESNO