Community Advocate Interest Form Community Health Worker Program This is a form for individuals who are interested in working with the Mobile Outreach Clinic and would like to request more information. First Name* Last Name* Year of birth* Email* Phone Number* Have you ever worked in a healthcare related field or community outreach?* Yes No Please describe your prior healthcare or community outreach role and it's responsibilities.What city and state do you currently live in?* Any other comments or questions?
