Student Training Program
First Name:
Last Name:
E-mail:
Telephone:
 
Do you have a high school diploma or GED? Yes
No
 
What city do you currently live in?
 
Are you a resident of Nebraska? Yes
No
Unsure
 
Which Program interests you?
Community Health Worker (CHW)
Provisionally Licensed Drug and Alcohol Counselor (PLADC)
Unsure or either
 
Are you a
Citizen of the United States
Non-citizen National of the United States
Foreign National who possesses a visa permitting permanent residence in the United States