Before proceeding to the application, please confirm the following. By checking the boxes below, you are stating that you understand each program requirement.* I am a resident of Travis County. I can commit to participating in a health equity training Aug. 2 & 3, 2019. I can attend the first workshop Tuesday, Aug. 13, 2019. I can commit to attending at least 4 of the 5 workshops. Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Gender* Male Female Other PronounPlease specify your pronoun. Home Address - Applicants must be residents of Travis County* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Twitter handle (if applicable)Employer*Position/Title*How did you hear about Community Health Champions?*Central Health WebsiteCentral Health e-NewsletterSocial MediaCommunity Health Champion AlumnusFriend/ColleagueRadioNewspaperDate of Birth* MM DD YYYY Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?*SelectYesNoAre you White, Black or African-American, American Indian or Alaskan Native, Native Hawaiian or other Pacific Islander, or some other race?*Select oneWhiteBlack or African-AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or other Pacific IslanderFrom multiple racesSome other raceWhat is the highest level of school you have completed or the highest degree you have received?Select oneLess than a high school degreeHigh school degree or equivalent (i.e. GED)Some college but no degreeAssociate degreeBachelor degreeGraduate degreePhD, JD, or DoctorateSchools/Universities attended*Degree(s)/Area(s) of Specialization*Other relevant certifications or trainingsWhat are your main hobbies or interests?*What languages do you speak?Your connectivity to other groups is important to help us get the word out about health initiatives. List any neighborhood, faith-based, boards/commissions, associations, or other groups, clubs or organizations you have participated or are currently participating in. Please separate by commas.*We are looking for the following traits in participants: (1) Commitment to improving the health of Travis County residents (2) Interest in current health care topics (3) Desire to grow in leadership and ambassadorship (4) Availability to participate in community activities and events. How do you feel you represent these traits?*Why would you like to join Community Health Champions? Please describe briefly.Do you have any more questions?