Community Health Worker Registration

This survey helps us secure funding to keep classes affordable

Choose Your Cohort
Fall Intro Zoom
Winter Intro Zoom

This CHW training course is an 8.5 week program which consists of two mandatory live classes and course material due each week. You must attend the intro zoom to begin the program. 

  • Check all options that apply for each question on the survey.
  • Only complete this survey one time. You may lose your place in line if you save over your first application.
  • Please plan your training dates to allow active participation in two 3.5 hour Zooms
  • Plan to spend 4 hours per week doing self-paced online coursework.
Sign above

Student Agreement

  1. I will attend both 3 ½ hour live sessions and understand that prompt attendance is expected. 
  2. I will text 775-538-2855 immediately if I am unable to join the Zoom or in-person workshop. 
  3. I will complete the weekly forums with 35-150 words each by answering the prompt completely, responding to at least one classmate, and providing feedback with what stood out in their post and why. 
  4. The online Instructor is assigned before classes begin. I will keep in contact with my Instructor when I have questions regarding assignments or due dates. 
  5. I will contact my Instructor in advance if I need to submit a weekly assignment late. 
  6. I will be prepared to present my 3-5 minute case study during the final Zoom class. 
  7. I will not copy work from other students or online sources without acknowledging them. 
  8. I will reach out to my Instructor to notify them when I made changes to assignments or added to my posts for a better grade. 
Your Contact Information (1 of 5)
  1. Type in the first few letters and then choose the organization where you work or volunteer.
  2. If it is not in the list, click "create new".
  3. Add the full name of your organization in this box and DO NOT abbreviate.
  4. Type 'None' or 'Unemployed' if you are not connected to an organization and are taking this class on your own.
  5. ❗Inaccurate employment information may make you ineligible for the program and result in a canceled registration.
Demographics (2 of 5)
Please do not add the month and day.
Are you Hispanic or Latino?
Do you identify as one or more of the following races?
Are you a veteran of the U.S. Armed Forces?
Disadvantaged Background
Disadvantaged background means a student who: 1. Comes from an environment that has inhibited them from obtaining the knowledge, skills, and abilities required to enroll in and graduate from professional training (Environmentally Disadvantaged); AND/OR 2. Comes from a low-income family (Economically Disadvantaged).
Level of education completed
Are you currently working?
Please share your level of fluency in the languages you read, write, or comprehend. You may add additional languages in this section:
Work or Volunteer Settings (3 of 5)
You can take this class even if you do not work in health care or at a non-profit! Check the communities that you are most connected with to get all the required fields and put a 0 in the number of clients box.
How many clients do you personally work with?
What population groups do you serve?
The United States uses categories that 30% of the population do not identify with. Please answer these as best as you can to help with grant reporting and accessing resources for underserved communities.
⭕ What race, country of origin, or ethnic groups best describes the clients you serve? For example, a client identifies as Asian and more specifically as Vietnamese. These are general notes to give context for the numbers and check boxes you have entered in the required categories.
Services that you work in
Would you like to be invited to stakeholder meetings for related grants and policies?
Counties Served
% of clients in urban and rural areas
Please separate entries with a comma and without spaces.
Goals and Interests (4 of 5)
Have you ever participated in a CHW training?
Are you a Community Health Worker now?

Including Health Support Worker, medical case manager, medical assistant, or certified Peer Support Specialist.

Do you plan to take the training as background for supervising other CHWs?
Do you plan to take the training as background for securing a volunteer/job/role?
Would you like to become a member of the Nevada Community Health Worker Association?
Only $20 per year!
What else would you like to share with us about your goals for this class and your career?
CHW Interest Groups
If I miss this class, please Invite me to future core classes

Demographics are reported as part of our State of NV, HRSA, SAMSA, and CDC grant funding. Reported information will be de-identified and not shared without your permission. This course costs about $300 per student and this survey helps us access grant funding so that CHW students do not have to pay the full cost for classes. Field placement support costs vary depending on the requirements from $450 to $2,200 dollars.

Course Fee (5 of 5)
Participant Fee

Call 775-538-2855 if you have questions about your payment selection.

Today's Date
Used to keep the registration survey date field on it's own line.

Payment Selection Flow Chart. Call if you do not know which option to select