Florida Community Health Worker Coalition Member Interest Form
New Member Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
Format: (000) 000-0000.
Please list your employer below. If you are not employed, please type "none" in the box below.
*
Are you a certified Community Health Worker (CHW)?
*
Yes
No
Please choose the option that BEST describes you:
*
Please Select
Community Health Worker (CHW)
Interest in CHW field
CHW Employer
Potential CHW Employer
Please choose the subgroup most relevant to your CHW interests:
*
Please Select
Networking/Communications
Research
Policy
Practice/Curriculum
Language Preference
*
Please Select
English
Spanish
Haitian Creole
Other
If you chose "other", please specify what your language preference is in the box below.
How did you hear about us?
*
Please Select
Social Media
Training Event
Community Event
Co-worker
Other
If you chose "other", please specify how you heard about us in the box below.
Please use the space below for any comments or questions you may have.
Click here to pay Annual Membership
fee.
Did you pay the (required) membership fee?
Yes
No
Submit
Should be Empty: