Community Health Worker Certification Application
A partnership between The Office of Violence Prevention (OVP) and Central Piedmont Community College.
Review the Scoring Rubric to See How Applicants are Evaluated
Basic Information
Section 1
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Name of Organization (if applicable)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you collaborated with OVP / ReCAST prior?
Yes
No
Community Connection
Section 2
Describe your involvement in your community
What organizations or groups are you connected to?
Passion & Motivation
Section 3
Why do you want to become a Community Health Worker?
Tell us about a time you helped someone in your community
Lived Experience
Section 4
Describe an experience that helped you develop empathy for others facing difficult situations. (Please only share within your comfort level).
Primary Community Zip Code Where Your Work is Focused
Section 5
Zip Code
Training Commitment
Section 6
Availability
Rows
Monday
Tuesday
Wednesday
Thursday
Friday
Morning
Afternoon
Evening
Are you able to commit to completing the full training program?
Yes
No
What challenges might impact your participation?
Submit
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