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
Email
Phone Number
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
I am a: (select all that apply)
Breast Cancer Survivor
Community Health Worker/Instructor
Family/Friend/Caregiver
Mental Health Provider
Nurse
Patient Navigator
Physician
Social Worker
Other
Please specify.
Are you a Certified Community Health Worker/Promotor(a)?
Yes
No
Please provide your CHW Certificate #
Are you a Certified Community Health Worker Instructor?
Yes
No
Please provide your CHWI Certificate #
Current Employer/Organization Affiliation:
Will the course completion certificate be submitted to your place of employment?
Yes
No
How did you first learn about this course?
My workplace
Other CHWs
Texas 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?
English
Spanish
No preference
Other
Please specify
Thank you for completing the registration.
Once you hit Submit you will be directed to a learning management system.
Create an account and bookmark the page so you may return if you don’t complete the training.
Once you create your account you will be able to enroll in courses.
You will be able to download your certificate once you submit an end of course survey
(use the Fill & Sign Tool to enter your name and date of completion)
Contact Information
