Home Health Aide Training Contact Form - Delaware County Literacy Council

First and Last Name(required)

Phone Number(required)

Email(required)

Best Way to Contact You-----If choosing email, please check your Spam folder for emails from DCLC

Phone Email

Best Time to Contact You (check all that apply)

Mornings Afternoons Evenings

Times You Are Available to Take Classes (check all that apply)(required)

Weekday Mornings Weekday Afternoons Weekday Evenings

Are there any times during the week that you are NOT available. Please list them.

Tell us why you are interested in DCLC’s Home Health Aide training. (Check ALL that apply)(required)

I want to learn a new skill. I want to start a new career in healthcare. I’m interested in becoming a nurse one day. OTHER (write answer below)

OTHER reason for interest in Home Health Aide training

Do you have a high school diploma or GED?(required)

Yes No

If you do not have a high school diploma, what is the last grade you finished?

Which of these do you have? Check all that apply.(required)

Computer / Laptop Tablet / IPad Cell phone None of these

Do you have Internet or Wifi access?(required)

Yes No Not Sure