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San Antonio Community Health Workers Association Membership Form
Membership form. The answers to these questions help us gather information to describe who we are as an Association and CHW workforce. Thank you for taking the time to share with us.
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* Indicates required question
Please enter your name (First and last name):
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Your answer
Phone Number:
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Your answer
Enter your preferred email address.
It can a Personal or professional email. For best practices, I recommend you use a personal but professional email address instead of your work email. Doing so keeps you connected with SACHWA even after parting ways with your employer or school.
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Your answer
Preferred method of contact:
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Email
Text
Phone call
Other:
Required
Please select the option that applies to you, I am a ...
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DSHS Texas certified CHW/Promotor
Non-certified CHW/Promotor
DSHS Certified CHW Instructor
CHW student
Other:
Required
If you are a certified CHW, How did you attain your CHW certification? please enter the name of the certification program you completed OR specify if you attained your certification based on experience.
Your answer
Department of State Health Services (DSHS) Search for a license/certificate Tool
https://vo.ras.dshs.state.tx.us/datamart/login.do;jsessionid=I9aMYzOCVvg0TcjVtB20xivlw-mGA6sZuKI5SQJQ.i-0f607d9f49e3fd568
Which category below includes your age?
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16-17
18-20
21-29
30-39
40-49
50-59
60-69
70 or older
Other:
If you are DSHS Texas certified CHW, please enter your CHW and/or CHWI certificate number
*
Your answer
Which of the following describes you?
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Hispanic
White
Black or African-American
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific islander
Other:
Gender: How do you identify?
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Man
Non-binary (A person whose gender identity does not fall within the binary genders of man or woman)
Woman
Prefer to self-describe, below
Other:
Pronouns Matter
Using personal pronouns is a form to show respect and a way to create an inclusive environment for all. To learn more about this follow this link:
https://www.mypronouns.org/
What pronouns do you prefer/use?
she/her/hers
he/him/his
they/them/theirs (singular)
ze/hir/hirs
Prefer not to answer
Other:
Clear selection
What is the highest degree or level of school you have completed?
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In High School
Some high school, no diploma
High school graduate, diploma or the equivalent
Some college credit, no degree
Trade/technical/vocational training (CHW Level 1 certificate)
Associate degree
Bachelor’s degree
Master’s degree
Doctorate degree
Other:
Employment Status: Are you currently…?
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Employed full time
Employed part time
Self-employed
Out of work and looking for work
Out of work but not currently looking for work
Volunteering
Seeking volunteering opportunities only
A student
Retired
Unable to work
Other:
What language (s) are you fluent in...?
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English Only
Spanish Only
English and Spanish
Other, please specifiy below
Other:
If employed, please enter your employer agency
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Your answer
Enter your job title (for example CHW, patient navigator, health educator e.t.c)
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Your answer
Enter your area of expertise (outreach, diabetes education, parenting classes, cancer patient navigation e.t.c
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Your answer
Enter the city, sate and zip code of the geographical area you serve through your work, volunteering and school internship activities
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Your answer
If you live in San Antonio/Bexar County, TX. Please enter your household's zip code.
Your answer
I am interested in joining San Antonio Community Health Workers Association (SACHWA). Mark all that apply to you:
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General Membership – Be notified and attend Events and Continuing Education programs.
Help promote event meetings/invites, and moderate open group forum.
Advocating for Community Priorities - Connecting priorities of community residents, employers and other working groups/coalitions that align with the field of Community Health to general group.
Assist in all advocacy projects to promote our profession.
Assist in updating and maintain the SACHWA’s website.
Actively develop CHW networks with agencies and organizations.
Interested in presenting to the group (work related projects, well researched topics of interest toward professional or skill set development)
Other:
Required
What do you expect from being a member of the SACHWA?
*
Your answer
If you have any comments or ideas, please enter them below.
Your answer
Association Monthly Meeting:
Currently, we host remote monthly meetings every fourth Thursday of the month from 3:00 pm to 5:00 pm. If interested in presenting, please email us at:
chw.nvca@gmail.com
to add you to our monthly calendar.
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