Apply: CNA & CHW Dual-Certification Program

Applications close November 20, 2026. Slots are limited — complete the form below to secure your spot.

Today’s Date
MM slash DD slash YYYY
Last 4 Digits of Your Social Security #*
Please enter a number from 0000 to 9999.
CONTACT INFORMATION
Name*
First Middle Initial Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Phone Type
May we send you text messages?
- Yes
- No
Email*
How did you hear about the CNA-CHW Dual Certification program?*
- Monterey County Works Representative
- Social Media
- Flyer
- Other
DEMOGRAPHIC INFORMATION
Date of Birth*
MM slash DD slash YYYY
Gender*
Selective Service (MALES ONLY)
Military Status*
If you are a Veteran you will be required to complete a WIOA Veteran Form at enrollment
Disability*
If “Yes”, you will be required to complete a WIOA Disability Form at enrollment
Authorized to Work in U.S.*
If U.S. Permanent Resident or Alien/Refugee:
Alien/Visa Registration #
Expiration Date
MM slash DD slash YYYY
Hispanic Heritage*
Race*
EMPLOYMENT INFORMATION
Employment Status*
If Employed, are you underemployed?
Registered Apprenticeship Program
Unemployment Insurance Eligibility
Number of Weeks Unemployed
Current/Previous Hourly Rate
Occupation
DISLOCATED WORKER ELIGIBILITY
Layoff Date
MM slash DD slash YYYY
Employer Name
Employer Address
Street Address Address Line 2 City State ZIP Code
Dislocation Hourly Rate
EDUCATION INFORMATION
Currently enrolled in school*
Highest Education Level*
High School Diploma or Equivalent Received*
PUBLIC ASSISTANCE
Temporary Assistance for Needy Families (TANF) – Recipient*
Supplemental Security Income (SSI) - Recipient*
General Assistance (GA)*
Supplemental Nutrition Assistance Program (SNAP)*
Refugee Case Assistance (RCA)*
Social Security Disability Insurance Income (SSDI)*
Receiving services under SNAP Employment & Training Program*
Receiving, or has been notified will receive, Pell Grant*
Ticket to Work Holder Issued by the Social Security Administration*
Foster Child (state or local payments are made for applicant)*
Youth currently living in high-poverty area*
Youth currently receives, or is eligible to receive free or reduced lunch under the Richard B. Russell National School Lunch Act*
BARRIERS
English Language Learner*
Basic Skills Deficient/Low Levels of Literacy*
Homeless*
Ex-Offender – individual has been arrested/convicted of a crime*
Displaced Homemaker*
Within 2 years of exhausting TANF lifetime eligibility*
Hawaiian Native*
American Indian/Alaskan Native*
Single Parent (including single pregnant women)*
Cultural Barriers*
FAMILY INCOME
Family Size*
Past 6 months Family Income*
If other, please explain:
PHOTO RELEASE
I agree that as a participant in the Monterey County Work’s programs and/or services, the use of any photographs taken that include my image or likeness may be used for any legal use including, but not limited to, publicity, copyright purposes, illustration, advertising, social media, and web content. Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
Signature
APPLICANT CERTIFICATION STATEMENT
I certify that the information on this application is accurate to the best of my knowledge. I understand that my willful misstatement of the facts may cause my forfeiture of rights in the WIOA Program and may result in criminal action. I give permission for outside sources to be contacted and for them to disclose any information necessary to verify my eligibility for WIOA. I further understand and agree that my social security number and other information on this application will be provided to other government agencies as required by law.
Signature*
Date*
MM slash DD slash YYYY

Apply: CNA & CHW Dual-Certification Program

CONTACT INFORMATION

DEMOGRAPHIC INFORMATION

EMPLOYMENT INFORMATION

DISLOCATED WORKER ELIGIBILITY

EDUCATION INFORMATION

PUBLIC ASSISTANCE

BARRIERS

FAMILY INCOME

PHOTO RELEASE

APPLICANT CERTIFICATION STATEMENT

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