CHW Interested Candidates

Please complete this form and submit it. All information shared on this form is private and is only view by the Heritage Care director of education.

Date*

Last Name*

First Name*

E-Mail*

Phone Number*

Availability*

When are you available Monday through Friday for class?

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Primary Area of Interest*

Please list the area of community health work that most interests you from the list

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Secondary Area of Interest*

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Primary Language*

Other Languages*

Work Permission in the U.S.*

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High School or GED*

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Street Address*

City*

County*

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Proof of Residence*

Can you provide a lease or utility bill that proves you live in the address listed?

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Income Statements*

Can you provide 6 months of paystubs to prove your income or a letter of support if you were unemployed?

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Married*

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Income for Spouse*

Can you provide 6 months of paystubs to prove your spouse's income or a letter of support if he/she was unemployed?

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Household Size*

How many people, including yourself, live in your house/apartment?

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Transportation

Will you need a transportation stipend to help cover the cost of getting to and from class?

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Childcare

Will you need childcare during your class hours?

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