Community Health Worker Paid Apprenticeship

Application for Services

Free · confidential · takes about 5 minutes

A note before you start

We only ask for demographics here. To keep you safe, we collect sensitive items, driver's license number, Social Security cards, pay stubs, bank statements, award letters, and leases, in person with a coordinator. If any question doesn't apply, leave it blank.

Which program are you interested in?

Program

You can pick more than one later , see all programs.

About you

Full legal name *

Date of birth

Marital status

Veteran or active-duty military?Yes, I'm a veteran or currently serving

Do you have a driver's license or state ID?Yes

We'll write the number down in person, please don't type it here.

Issued state

How we can reach you

Phone

Best time to reach you

Preferred contact

Phone callTextEmail

Please give us at least one, phone or email, so we can follow up.

Where you live

Street address

City

State

ZIP

County

Household & income

Are you the head of household?Yes

Your monthly income (before taxes)

Others in your household

Include children, spouse/partner, or anyone else living with you.

No one else added yet, that's fine if you live alone.

What do you need help with?

Tell us in your own words

Consent & Release

See our privacy summary for details on how we protect your information.

I authorize East Texas Alliance of Hope to contact me and to share the information in this application with partner agencies, providers, and community organizations the Alliance reasonably believes may be able to help me. I understand I can withdraw this authorization at any time in writing. *Optional: You may include faith-based organizations and churches among the partners you contact on my behalf. (Leave unchecked and we won't share with faith-based partners.)I understand that East Texas Alliance of Hope does not guarantee any specific service, benefit, eligibility, or outcome. The Alliance coordinates connections; each partner makes its own decisions. I release East Texas Alliance of Hope and its staff and volunteers from any claim arising from a partner's decision or from services I choose to accept or decline. *

Type your full name to sign *

Typing your name and pressing "Submit application" is your electronic signature. We'll record the date and time.

Just talk to someone instead