Training Request Form

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This request form is to be submitted at least 3 months prior to the requested start date. Please note that submission of this form does not officially reserve the dates requested. Trainings are offered based on CHWI’s facilitator and training team’s capacity.

If you are requesting training please have a cohort of at least 10 participants identified. If you do not have 10 participants identified, the remaining seats in the cohort will be open to the general public. This same regulation applies when requesting training on-site or in a location of your choosing. This form is NOT for individual core competency request.

If you are requesting training to be offered in a venue provided by CHWI, the location will be determined based on the concentrated area of demand.

Name of your organization: *

First and last name of point of contact: *

Email address for point of contact: *

Please select the training(s) you are requested to be facilitated: *

CHW Core Competency Training (For groups only. Individuals please fill out the course application.)

PASOs CHW Core Competency Training

CHW Supervisor Training

Adolescent Maternal & Child Health

Adolescent Sexual Health Specialty Training

Diabetes Management & Prevention Specialty Training

Health & Racial Equity Specialty Training

LGBTQIA+ Specialty Training

Opioid Misuse Prevention Specialty Training

Oral Health Specialty Training

Perinatal Specialty Workshop

Telehealth Specialty Training

Other:

Required

Preferred start date of training: *

YYYY

By submitting this form, I acknowledge that I have read and completed all of the above CCHA Training Request Form Application to the best of my knowledge. *

Yes

Required

By submitting this form, I acknowledge that all training requests are to be vetted and approved by the CCHA Training Staff. *

Yes

Required

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