Thank you for your interest in taking this training. All four courses in the series, “Understanding the Psychosocial Impacts of Breast Cancer”, are free of charge. Please take a couple of minutes to complete the registration below.

First Name

Last Name

Phone Number

City

State

Zip Code

I am a: (select all that apply)

Breast Cancer SurvivorCommunity Health Worker/InstructorFamily/Friend/CaregiverMental Health ProviderNursePatient NavigatorPhysicianSocial WorkerOther

Please specify.

Are you a State of Texas Certified Community Health Worker (CHW)/Promotor de Salud?

YesNo

Please provide your CHW Certificate #

Are you a State of Texas Certified Community Health Worker Instructor (CHWI)/Promotor de Salud Instructor?

YesNo

Please provide your CHWI Certificate #

Are you a State of Michigan Certified Community Health Worker (CHW)/Promotor de Salud?

YesNo

Please provide your MI CHW Certificate #

Are you a State of Michigan Certified Community Health Worker Instructor (CHWI)/Promotor de Salud Instructor?

YesNo

Please provide your MI CHWI Certificate #

Current Employer/Organization Affiliation:

Will the course completion certificate be submitted to your place of employment?

YesNo

How did you first learn about this course?

My workplaceOther CHWsTexas Department of State Health Services (DSHS)Breast Cancer Resource Center (BCRC)Michigan Community Health Worker Alliance (MiCHWA)Other

Please specify

What other types of courses would you be interested in?

In what language(s) would you prefer educational courses?

EnglishSpanishNo preferenceOther

Please specify

Thank you for completing the registration. After submitting this form you will be asked to create an account.

As a friendly reminder, bookmark the next page so you can easily access this training in the future.

Contact Information