Application Form CHW CONNECT App Form Heading link Copy link Step 1 of 4 - Qualifications and Commitment Agreement 0% Application Info and EducationName * Required First Last Home Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email * Required Phone number where best to reach you: * RequiredDate of Birth: * Required MM slash DD slash YYYY Highest level of education completed * RequiredLess than high schoolHigh school diploma or equivalentSome college, no degreePost-secondary non-degree awardAssociate's DegreeBachelor's DegreeMaster's DegreeDoctoral or Professional DegreeMonth/Year this education completed: * Required Name and location of institution where highest level of education was completed. * Required e.g. University of Illinois at Chicago, IL or Columbia College, IL Employment InfoAre you currently employed? * Required Yes No (This information does not impact acceptance)If employed, what is the name of your employer? * Required Enter N/A if not employedWhat is your full job title? * Required Enter N/A if not employedHow long have you worked for this employer? * Required Enter N/A if not employedHave you ever worked, or are you currently employed as a Community Health Worker or public health program? * Required Yes No If you answered Yes, are you a Certified Community Health Worker? * Required Yes No Confirmation of Qualifications and RequirementsHow did you learn about this program? * Required Chicago Housing Authority (CHA) UI Health UI Health Volunteer Services Envisions Community Services (ECS) Illinois Community Health Workers Association (ILCHWA) Other The following technology is required to participate. (working computer/laptop, webcam, microphone, speakers and reliable internet connection for the duration of each class.) If you don't have access to these technologies, we will assist you in obtaining them. Do you have access to the mentioned technologies? * Required Yes No To be eligible for acceptance in the Community Health Worker Training Program, applicants must be 18 years or older and have earned a high school diploma or GED. * Required Yes - I meet these qualifications No - I do not meet these qualifications I understand and acknowledge this online application does not guarantee enrollment into the program. * Required Yes No Note: Participants are accepted in the program in the order their completed applications are received.On a level of 0-5, how do you rank your proficiency with Microsoft Office applications? * Required 0 = never used them, 1 = low, I often need help, 5 = proficient, I don't need any help Other InformationWhy are you interested in taking this course? * RequiredIn a brief paragraph, share what you intend to gain from the program and how it aligns with your professional development goals.*