San Antonio Community Health Workers Association Membership Form
2021 Updated membership form. The answers to these questions help us describe who we are as an Association.
Please enter your name (First and last name): *
Phone Number: *
Preferred email address (Personal or professional email) *
Preferred method of contact: *
Required
Please select the option that applies to you, I am a ... *
Required
If you are a certified CHW, How did you attain your CHW certification? please enter the name of the certification program you completed OR specify if you attained your certification based on experience.
Department of State Health Services (DSHS) Search for a license/certificate Tool
If you are DSHS Texas certified, please enter your CHW and/or CHWI certificate number *
Which category below includes your age? *
Which of the following describes you? *
Gender: How do you identify? *
Pronouns Matter
Using personal pronouns is a form to show respect and a way to create an inclusive environment for all. To learn more about this follow this link: https://www.mypronouns.org/
What pronouns do you prefer/use?
Clear selection
What is the highest degree or level of school you have completed? *
Employment Status: Are you currently…? *
What language (s) are you fluent in...? *
If employed, please enter your employer agency *
Enter your job title (for example CHW, patient navigator, health educator e.t.c) *
Enter your area of expertise (outreach, diabetes education, parenting classes, cancer patient navigation e.t.c *
Enter the city, sate and zip code of the geographical area you serve through your work, volunteering and school internship activities *
If you live in San Antonio/Bexar County, TX. Please enter your household's zip code.
I am interested in joining San Antonio Community Health Workers Association (SACHWA). Mark all that apply to you: *
Required
What do you expect from being a member of the SACHWA? *
If you have any comments or ideas, please enter them below.
Association Monthly Meeting:
Currently, we host remote monthly meetings every fourth Thursday of the month from 2:00 pm to 4:00 pm. If interested in presenting, please email us at: chw.nvca@gmail.com to add you to our monthly calendar.
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