Screening Questions for Community Health Worker Program Applicants
This form is to serve as a mode of contact information collection and the initial application for anyone looking to participate in Community Health Worker Core Competency Training. Section one is the contact/demographic information section and section two is the screening question sections. Contingent upon the quality of responses given to the questions below, applicants may be granted eligibility to participate in the CHW Core Competency Training. For more information on the training, please follow this link: https://communityhealthalignment.org/training-faq/

Standard cost: $1850.00, discounted rates are available for those who qualify
Next training iteration is being offered in-person, Tuesday & Thursday, 9 am - 4 pm with a break for lunch

If you have any questions regarding registration or training, please contact our Training Assistant, Mychelle Harris, at mychelle@sc.edu or at (803) 673-3935.
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Email *
Full Name *
Email Address *
Phone Number *
Start date of Core Competency Training you would like to participate in *
Who is paying for your training? *
Bill to: (name of organization) *
Required
Bill to: (address to be used for invoicing) *
Required
First and Last name of person invoice for payment should be sent to *
If receiving financial support through previously established agreement, please put your point of contact's first and last name.
Email of person invoice for payment should be sent to *
If receiving financial support through previously established agreement, please put your point of contact's email. For any questions regarding logistics of payment please contact Evangeline Cornelius at ecorneli@mailbox.sc.edu.
Phone number of person invoice for payment should be sent to *
If receiving financial support through previously established agreement, please put your point of contact's phone number.
If receiving financial support through grant or other previously established agreement, please provide the grant name or note agreement below.
What is your organization's EIN? (Federal Employer Identification Number) *
If self-pay or receiving financial support through previously established agreement, please put N/A.
Current Place of Employment (if applicable) *
Title at Current Place of Employment (if applicable) *
Brief Description of Current Position *
Brief Description of Current Occupation if not formally employed *
City where current place of employment is located (or city you currently live in) *
Would you be willing and able to participate in a training if it were outside of the city you currently live in ? *
If so, how far would you be willing to commute *
Should COVID-19 restrictions change, would you be available to attend in-person training? *
If you answered NO to the above question, please explain your answer briefly (ex- scheduling conflict, budget constraints, restricted company travel, etc)
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