Community Health Fellows Program Host Site Application - Community Clinic Association of Los Angeles County

2026-2027 Community Health Fellows Host Site Application

CCALAC is excited to offer the Community Health Fellows program for the 2026-2027 program year. If your health center site would like to be a new site or continue to be a host site, please complete this form. If you have any questions, please e-mail Johnette Gonzalez, Workforce Pathway Program Manager at jgonzalez@ccalac.org

Phone

This field is for validation purposes and should be left unchanged.

Contact Information

Health Center Name(Required)

FIRST and LAST Name of individual completing this form(Required)

Title(Required)

Email(Required)

Enter Email Confirm Email

Phone(Required)

Community Health Fellows

Please enter total # of requested Community Health Fellows (Maximum of 5)(Required)

Please enter a number from 1 to 5.

Community Health Fellows must serve in person. Will your health center be able to host the Health Fellows in person? (providing them the necessary desk space, computer, etc.)(Required)

What Department(s) will the Community Health Fellows work in? (Example: outreach, health education, case management, etc.)(Required)

What will the Community Health Fellows do? Please provide as much detail and information as possible. (For example: outreach, health education, case management, screenings, etc.). The Health Fellows must have direct interaction with patients (either through phone, in-person, etc.)(Required)

Who will supervise the Community Health Fellows? (Please provide their name, titles, and e-mails)(Required)

Please list the anticipated health center location(s) - Address where the Community Health Fellows will serve.(Required)

Please list any questions or request you may have.(Required)

My health center is capable of paying the required health center site match of $16,000 per Community Health Fellow (If selected to move forward, host site health center will be required to sign an MOU/MOA detailing payment).(Required)

YES

Signature (please sign to confirm you have permission from your health center to submit this application). If selected to move forward you will have to sign an MOU/MOA before interviewing applicants.(Required)