CHW Training Interest Form

Eastern Shore AHEC — September 2026 Cohort

Thank you for your interest in the CHW Training program with Eastern Shore AHEC, beginning September 22 and ending October 24, 2026.

⚠️ Submission of this form does not guarantee acceptance.

Program Overview

Schedule: Tuesdays & Thursdays 5:30 – 8:30 PM | Saturdays 9:00 AM – 12:00 PM

Format: Virtual classroom — access to a computer and reliable internet is required.

Full participation is required. If you cannot commit to attending all sessions, please consider delaying your participation until you can fully commit.

The CHW training course also requires classwork outside the training sessions as well as a 40-hour practicum experience.

Contact Information

Full Name *

Phone Number *

Home Address *

Personal Email Address *

Current Work / Employer

Job Title

Personal Statement

Explain why you would like to become a certified community health worker. *

Share how you are currently connected and working with your community and what inspires you to serve your community. *

Explain why you think you’d make a good community health worker. What qualities and values do you possess? *

Eligibility Acknowledgments

Please confirm the following:

I am at least 18 years of age I have a high school diploma or GED I have access to reliable internet and a desktop or laptop computer

Commitment Agreements

By checking each box, I agree to the following:

Complete a virtual interview with an Eastern Shore AHEC team member Commit to attending all training sessions and completing coursework within specified timelines Commit to completing the 40-hour field practicum experience within the identified timeline Commit to obtaining my Maryland CHW certification within 3 months of receiving my MAHEC CHW certificate Commit to working as a CHW in Maryland Complete the official registration form completely after being selected for the training program

Certification & Signature

I certify that all information provided is accurate and complete. I understand that submission of this Interest Form does not guarantee acceptance into the training program.

Signature (type your full name) *

Date *