ASPIN 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.

Date of Application: *

Name: *

First

Last

Home Address: *

City: *

State: *

Zip Code: *

County: *

Primary Phone: *

Secondary Phone:

Email Address: *

Alternative Email:

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

Yes
No

If no, do you work in Indiana?

Yes
No

Are you over the age of 18? *

Yes
No

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 have a high school diploma or equivalent? *

Yes
No

Highest Level of Education: *

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:

If yes, Employer County:

Current Wage:

Supervisor Name:

Supervisor Email:

Are you currently employed as a Community Health Worker? *

Yes
No

Have you ever been certified as a Community Health Worker? *

Yes
No

Have you completed any other type of Community Health Worker Training? *

Yes
No

How many years of experience do you have working in the Mental Health Field? *

How many years of experience do you have working in the Addiction Field? *

How many years of experience do you have working with chronic health conditions? *

How many years of experience do you have working in a role comparable to a Community Health Worker? *

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

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

CHW Training Funding: *

My organization will be paying the $1,250 for my CHW training. (There is a $25 processing fee for payments made with credit card.)
I will be paying the $1,250 for my CHW training. (ASPIN does not accept personal checks, there is a $25 processing fee for payments made with credit card.)
I would like to apply for a scholarship to pay for my training.

If you or your organization will be paying for the training please provide the email address of where the invoice should be sent:

Which program are you most interested in?

CHW Only/Private Tuition
ASPIN Behavioral Health Workforce Education and Training Program for Paraprofessionals (BPP)
ASPIN Community Health Worker Training Program (ACHWTP)
ASPIN Workforce Innovation
Undecided/No preference

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/files/Email%20Whitelist%20Procedure.pdf. Please sign your name below to acknowledge this procedure or contact mglenn@aspin.org for more clarification. *

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: *

Date: *