Student Interest Form

Student Interest Form

Program of Interest (Select all that apply):

Are you currently employed as a Direct Care Worker?

Examples include: Private Caregivers, Home Care Aides, Care Coordinators,Care Managers, Dementia Care Specialists, Non-IHSS Affiliated Personal Care Assistants, Activities Coordinators, Transportation Providers.

As a requirement of California Department of Aging, please complete the below demographic information:

Gender Identity: (Select all that apply)

Racial / Ethnic Background: (Select all that apply)

Language/s Spoken: (Select all that apply)