ASPIN WFI Training Application

Please complete the application in its entirety. If the question does not apply, please put N/A. Do not leave any questions blank. Incomplete applications will disqualify you from an interview and enrollment.

The goal of the ASPIN Workforce Innovation program is to train high school aged youth from traditional and non-traditional learning institutions to become Certified Community Health Workers. Are you between the ages of 16-21? *

Yes
No

Check out ASPIN’s other training options here: ASPIN Training

Date of Application: *

Name: *

First

Last

Home Address: *

City: *

State: *

Zip Code: *

Indiana County: *

Highest Level of Education: *

Name of High School or Career Center: *

Expected Graduation Date: *

Primary Phone: *

Secondary Phone:

Email Address: *

Alternative Email:

Are you a current resident of the state of Indiana? *

Yes
No

How old are you? *

Have you or a family member served in the U.S. Military? (check all that apply) *

I have served in the military.
I have a family member who has served in the military.
None of the above.

Branch of Service: *

Do you speak any languages other than English? *

Yes
No

If yes, which language(s) do you speak? *

Do you own or have access to a computer? *

Yes
No

Do you have access to the internet? *

Yes
No

Are you currently employed? *

Yes
No

If yes, Employer *

If yes, Position/Title: *

What is your parent/guardian's highest level of education: *

Why would you like to become a Community Health Worker? *

What are your plans after graduation? *

Start working
Enroll in a 2-year program
Enroll in a 4-year program
Undecided

If you plan to enroll in a 2-year or 4-year program, what school or program are you interested in? *

What makes you a suitable candidate to serve your community as a Community Health Worker? *

Language Preference: *

How did you hear about the ASPIN CHW training? *

We have found that free email accounts like Gmail and Yahoo mail tend to block many email addresses. To ensure that you receive the necessary emails (including a reply to this application) from ASPIN instructors, if you are using accounts from those providers, we request that you read and follow the procedures listed at https://aspin.org/wp-content/uploads/2024/10/Email-Whitelist-Instructions-1.pdf. Please sign your name below to acknowledge this procedure or contact llewis@aspin.org for more clarification. *

Clear Signature

I attest that I have given true, accurate, and complete information on this form to the best of my knowledge and understand any false information or omissions may affect my eligibility for certification.

Signature: *

Clear Signature

Date: *