CHA Renewal Data Sheet

Member Data Sheet
I. INFORMATION FOR HWI DIRECTORY
Name*
Address*

Address

Street Address Line 2

CityProv / County

Postal CodeCountry
Grad Date

YearMonthDay
Date
II. INFORMATION FOR HWI WEBSITE
Phone #
Email
example@example.com
Website
City
Have you changed your contact information in the past year?*
III. CERTIFICATION REQUIREMENTS
1. Professional Liability Insurance (select one)*

Insurance coverage (attach certificate)I am covered by government equivalent in my area (attach explanation)
Name of InsurerExpire Date of Policy
Upload Proof of Insurance Documentation

Upload evidence of insurance NOT a receipt for payment
Cancelof
Upload Explanation of Equivalent Government Coverage

Cancelof
2. Health Department Compliance (select one)*

I am current with all health department requirements in my geographic area.I am NOT current with all health department requirements in my geographic area.
My complete CE hours for certification requirement are listed below and my certificates are attached*
Please indicate the name and date, provider and hours per course separately above
NOTE: CE Hours are tracked on a 2yr cycle (24 CE hrs per cycle) starting in 2024. You can list your current and or accumulated CE hours acquired above. If you are below the required hours for the 2yr cycle, you can request an extension from HWI CE Committee describing your plan to complete requirement. Attach additional page if needed
Upload CEC Documentation

You can upload multiple files if needed
Cancelof
4. Professional Licensure*

I am current with all professional licensure required in my geographic areaNo professional licensure is required in the geographic area where I practiceI am NOT current with all professional licensure required in my geographicarea (attach explanation)
Explanation

Please attach an explanation for not being current with professional licensure
Cancelof
I verify on,enter date*(date), that the Data Sheet information I am submitting is true and accuratel
Please Select Signature type below*

I am using a desktop / laptop computerI am using a mobile device / tablet
Please provide a signature
Enter your name as a signature
Should be Empty:

Member Data Sheet

I. INFORMATION FOR HWI DIRECTORY

II. INFORMATION FOR HWI WEBSITE

III. CERTIFICATION REQUIREMENTS