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First Name *
Username *
Last Name
User Email *
Ethnicity *
--Select Ethnicity--
African (Black)
African American
Alaska Native
American Indian
Asian Indian
Carribean ( Black )
Chinese
Eastern European
Filipino / a
Guamanian or Chamorro
Hispanic or Latino Central American
Hispanic or Latino Mexican
Hispanic or Latino South American
Hmong
Indigenous Mexican, Central American or South American
Japanese
Korean
Laotian
Micronesian
Middle Eastern
Native Hawaiian
North African
Other
Samoan
Slavic
South Asian
Tongan
Vietnamese
Western European
Do not know / Unknown
Other Asian
Other Black
Other Hispanic or Latino
Other Pacific Islander
Other White
Decline / Will not answer
User Password *
Zip Code *
Confirm Password *
Gender
--Select Gender--
Male
Female
Trans Female / Trans Woman
Trans Male / Trans Man
Genderqueer, Gender Non-conforming, or Nonbinary Gender
Private Email
Languages Spoken (Select all that applies)
English
Spanish
French
Mandarin Chinese
Swahili
Hindi
Russian
Standard Arabic
Portuguese
Bengali
Other
Position Title
--Select Position Title--
Community Health Worker (employed)
Community Health Worker (volunteer)
Care Manager (not licensed as a nurse or other licensed professional)
Community Advocate
Community Health Advisor/Promoter
Community
Doula
Home Visitor
Lay Health Promoter/Promotores de Salud
Lifestyle Coach/Advisor
Outreach Worker
Patient or Client Navigator
Peer Support Specialist
Other
Other
Certification Status
--Select Certification Status--
Community Health Worker - Certified
Community Health Worker - Not Certified
Peer Recovery Specialist - Certified
Work Localities
--Select Work Localities--
Statewide
Accomack
Albemarle
Alleghany
Alexandria City
Amelia
Amherst
Appomattox
Arlington
Augusta
Bath
Bedford
Bland
Botetourt
Bristol City
Brunswick
Buchanan
Buckingham
Buena Vista City
Campbell
Caroline
Carroll
Charles City
Charlotte
Charlottesville City
Chesapeake City
Chesterfield
Covington City
Craig
Culpeper
Cumberland
Danville City
Dickenson
Dinwiddie
Emporia City
Essex
Fairfax
Fairfax City
Falls Church City
Fauquier
Floyd
Fluvanna
Franklin
Franklin City
Fredericksburg City
Galax City
Giles
Gloucester
Goochland
Grayson
Greene
Greensville
Halifax
Hampton City
Hanover
Harrisonburg City
Henrico
Henry
Highland
Hopewell City
Isle of Wight
James City
King and Queen
King George
King William
Lancaster
Lee
Lexington City
Loudoun
Louisa
Lunenburg
Lynchburg City
Martinsville City
Mathews
Mecklenburg
Middlesex
Montgomery
Middlesex
Nelson
Norfolk City
Northumberland
Norton City
Nottoway
Orange
Page
Patrick
Petersburg City
Pittsylvania
Poquoson City
Portsmouth City
Powhatan
Prince Edward
Prince George
Prince William
Pulaski
Radford City
Rappahannock
Richmond Country
Richmond City
Roanoke Country
Roanoke City
Rockbridge
Rockingham
Russell
Salem City
Scott
Shenandoah
Smyth
Southampton
Spotsylvania
Suffolk City
Surry
Sussex
Tazewell
Virginia Beach City
Warren
Waynesboro City
Washington Country
Westmoreland
Williamsburg city
Winchester city
Wise
Wythe
York
Work Status
--Select Work Status--
Full-time employee
Part-time employee
Not currently employed
Community Health Worker Volunteer
Association Membership
Virginia CHW Association (VCHWA)
National CHW Association
Other Association
Not any Association member
Permission to Contact You to Share INFORMATION about VCHWA
Yes
No
If Certified: Certification Number
If Certified: Expiration Date
Will you like to Mentor another CHW?
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No
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Questions & Inquiry Contact
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