INCHWA Membership Form

Please choose the appropriate Membership Level based upon the following criteria:

Volunteer CHW: You volunteer as a CHW but are not a paid employee.
Certified CHW: You have been certified through an INCHWA-approved training vendor- HealthVisions Midwest.
General Membership: You have been trained as a CHW through another training vendor, OR you who would simply like to become a member of INCHWA.

Membership Level:

Volunteer CHW - $20

Certified CHW (Through an INCHWA-Approved Training Vendor)- $40

General Membership- $50

The membership you have selected will automatically renew.

Personal Information

First Name: Last Name: Home Address: City: State: Zip: - County: Business Phone: Personal Phone: Business Email: Personal Email: Preferred Method(s) of Communication (Check all that apply):

Personal Email

Work Email

Personal Phone

Work Phone

Are you currently employed?: Employer: Job Title:

Demographics

Birth Date: / / Ethnicity: Highest Level of Education: I will pursue higher education in the next: Languages Spoken: Proficient in (Check all that apply):

Oral Communication

Reading

Written Communication

Professional Affiliations: Please list any additional education/certifications that you have: Social Media Preferences (Check all that apply):

Facebook

Instagram

Twitter

YouTube

CHW Profile

I received my CHW training from: Client Population: How do you relate to the community you serve? (Check all that apply):

Health condition (diabetes, hypertension, etc.)

In recovery

Neighborhood

Race/ethnicity

Socioeconomic status

Spoken language other than English

Other

I am not currently working as a CHW.

What percentage of your time as a CHW is spent addressing health-related tasks (i.e. disease management, disease prevention, wellness, etc.): What percentage of your time as a CHW is spent addressing social service tasks (i.e. access to care, housing, food insecurity, insurance navigation, etc.): What is your PRIMARY area of focus as a CHW?: What is your SECONDARY area of focus as a CHW?: What is your TERTIARY area of focus as a CHW?: In the event of a public health emergency, I am available to assist in the following counties (Check all that apply):

Areas of Interest

Which, if any, specific people groups do you have a passion for serving?: Which, if any, specific people groups would you like to learn more about?: I am interested in trainings on the following social service topics (Check all that apply):

Access to Care

Child Care

Community Building

Employment

Food Aid

Housing/Homelessness

Social Support

Transportation

Other

I am interested in trainings on the following health topics (Check all that apply): I am interested in learning more about the following self-care areas (Check all that apply):

Emotional

Intellectual

Mental

Physical

Safety and Security

Social

Spiritual

I am interested in learning more about becoming a (Check all that apply):

INCHWA Board Member

INCHWA Committee Member

INCHWA Outreach Ambassador

None of the above

To manage your account (i.e. renew membership, access trainings and resources, upload CEUs, etc.), please create a login name and password below. Your password must be at least eight characters long, and contain at least one number.

Create a Login Name: Password: Retype Password:

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