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Registration Form
First name
*
Last name
*
Multi-line address
Country/Region
Address
City
Zip / Postal code
Birthday
*
Month
Day
Year
Email
*
Phone
Are you at least 18 years of age?
Yes
No
Do you have a valid government-ID?
Yes
No
Which class are you applying for?
Day 8:30am - 3:00pm
Evening 4:00pm - 9:15pm
Can you attend ALL scheduled class dates/times?
Yes
No
Do you have reliable transportation?
Yes
No
Are you able to meet physical requirements of CNA duties (lifting, standing, bending)?
Yes
No
Are you willing to complete required health screenings (TB test, immunizations)?
Yes
No
How do you plan to pay for the program?
Pay in full
Payment plan
Sponsorship/Scholarship
Do you understand all fees must be paid before attending clinical rotation?
Yes
No
Have you ever been listed on a Nurse Aide Abuse Registry?
Yes
No
Have you ever been convicted of a felony or misdemeanor that may affect your eligibility to work in healthcare?
Yes
No
Submit Form
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