INTEREST FORM
Submit your interest to join the Community Health Champions in 2016.
If you are interested in participating in Community Health Champions in 2016, please complete the interest form
below and submit by Monday, January 18, 2016. Participants must be at least 18 years of age and reside in Travis
County, Texas, and commit to attending four of five workshops.
CONTACT INFORMATION
Name
Street Address
City, State, Zip Code
Home Phone
Work Phone
E-Mail Address
ABOUT ME
Current employment or
area of study
Languages spoken
Hobbies / interests
Race / Ethnicity
EDUCATION
Schools / Universities
attended
Degrees / Areas of
specialization
Other certifications or
trainings
To submit interest form: Scan and email to Claudia.Herrington@centralhealth.net; mail to 1111 E Cesar Chavez,
Austin, TX 78702; or complete an online interest form: www.centralhealth.net.
Applicants will be notified of acceptance status on or before Friday, January 22, 2016.
INTEREST FORM
Your connectivity to other groups is important to help us get the word out about health
initiatives. Please share your own personal network you can use to improve community health:
CLUBS, ORGANIZATIONS, NEIGHBORHOOD, FAITH-BASED OR OTHER
GROUPS: Please list and state your role.
WHY IS IMPROVING THE HEALTH OF YOUR COMMUNITY IMPORTANT
TO YOU? Describe briefly.
WHY DO YOU WANT TO BE A PART OF COMMUNITY HEALTH
CHAMPIONS? Describe briefly.
DESCRIBE ANY RELEVANT VOLUNTEER OR WORK EXPERIENCE.
To submit interest form: Scan and email to Claudia.Herrington@centralhealth.net; mail to 1111 E Cesar Chavez,
Austin, TX 78702; or complete an online interest form: www.centralhealth.net.
Applicants will be notified of acceptance status on or before Friday, January 22, 2016.
INTEREST FORM
AREAS OF INTEREST
If you are selected to be a part of Community Health Champions, your feedback on topics will help shape
the workshops and activities. Please respond to your level of interest in the topics below:
Topic
Combating health
disparities
Health care innovation
Behavioral health
HIV prevention and
treatment
Diabetes prevention and
treatment
Reducing tobacco use
Obesity prevention
Women’s health services
Visits and tours of local
community health centers
Behind the scenes at the
Dell Medical School at The
University of Texas at
Austin
Level of Interest (circle one for each topic)
Very Interested
Somewhat Interested
Neutral Not Very Interested Not interested
Very Interested
Somewhat Interested
Neutral Not Very Interested Not interested
Very Interested
Somewhat Interested
Neutral Not Very Interested Not interested
Very Interested
Somewhat Interested
Neutral Not Very Interested Not interested
Very Interested
Somewhat Interested
Neutral Not Very Interested Not interested
Very Interested
Very Interested
Somewhat Interested
Somewhat Interested
Neutral Not Very Interested Not interested
Neutral Not Very Interested Not interested
Very Interested
Somewhat Interested
Neutral Not Very Interested Not interested
Very Interested
Somewhat Interested
Neutral Not Very Interested Not interested
Very Interested
Somewhat Interested
Neutral Not Very Interested Not interested
Other topics: (please list)
ADDITIONAL INFO
T-shirt size:
Size: S
M
L
XL
XXL
XXXL
Date of Birth: Month / Day
By submitting this application, I am committed to participate in the Community Health
Champions group presented by Central Health. I confirm that the information submitted in
this application is correct. I have reviewed the meeting schedule and can attend at least 4
out of 5 of the meetings.
Name (printed)
Signature
Date
OUR POLICY
It is the policy of this organization to provide equal opportunities without regard to race, color, religion,
national origin, gender, sexual preference, age, or disability.
Thank you for completing this application form and for your interest in participating in the Community
Health Champions in 2016.
To submit interest form: Scan and email to Claudia.Herrington@centralhealth.net; mail to 1111 E Cesar Chavez,
Austin, TX 78702; or complete an online interest form: www.centralhealth.net.
Applicants will be notified of acceptance status on or before Friday, January 22, 2016.