Community Health Worker Program Waiver Request
Use this form to request a waiver, exception, or accommodation related to participation in a community health worker program.
Requester and Program Details
Requester Full Name
*
First Name
Middle Name
Last Name
Preferred Contact Method
*
Phone
Email
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Community Health Worker Program Name or Location
*
Participant Relationship to the Program
*
Participant
Parent/Guardian
Caregiver
Staff Member
Other
Waiver Request Information
Reason for Waiver Request
*
Requirement or Rule to Be Waived or Modified
*
Requested Accommodation or Exception
*
Is This Request Urgent?
*
Yes
No
Date Waiver Is Needed By
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supporting Context or Circumstances
Follow-up and Acknowledgement
Preferred Follow-up Method
*
Phone
Email
Either
Best Time to Contact
Hour Minutes
AM
PM
AM/PM Option
Submit request
Should be Empty: