In-Person Community Health Worker Training Application (Northern California)

I am interested in applying to participate in the Partners in Care Foundation In-Person Community Health Worker Training Program.

I understand that I will be required to attend classroom sessions Monday, October 2nd – Friday, October 6th  and Monday, October 23rd – Friday, October 27 I understand that I will also be required to apply the skills in the field Monday, October 9 – Friday, October 20 and to provide an attestation from my employer verifying the field experience.

I also agree to provide the following:

Core Competency Observation
Statement of Interest (300-word limit)

I understand that my application will be assessed according to the following criteria:

Experience in the field of Community Health Work
Statement of Interest

Date(Required)

Applicant's Full Name(Required)

Employer/Volunteer Site Name(Required)

Employer/Volunteer Site Phone #(Required)

Employer/Volunteer Site Address

Street Address Address Line 2 City State ZIP Code

Applicant's Position at Employer/Volunteer Site(Required)

Employer/Volunteer Supervisor Printed Name(Required)

By Checking This Box, You Are Certifying That You Are 18 Years or Older(Required)

By Checking This Box, You Are Certifying That You Are 18 Years or Older

By Checking This Box, You Are Certifying That You Are a Current California Resident(Required)

By Checking This Box, You Are Certifying That You Are a Current California Resident

Signed Core Competency Observation Form(Required)

Max. file size: 2 MB.

(Download Form Here)

Statement of Interest (300 Word Limit)(Required)