QMA Application - $100 (Non-Refundable)
First Name
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Last Name
*
Maiden Name (If Applicable)
Date of birth
*
Gender
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Male
Female
Prefer not to answer
Address
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City
*
State
*
Postal code
*
Email
*
Phone
*
Have you worked as a CNA for a minimum of 1000 hours within the last 24 months?
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Yes
No
Do you currently work in a nursing home or assisted living facility?*
Yes
No
Are you currently a CNA?
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Yes
No
Have you received the Covid Vaccination?
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Yes
No
Do you have proof of your Covid Vaccination?
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Yes
No
Not Applicable
Do you have documentation of a medical or religious exemption?
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Yes
No
Not applicable
Are you a citizen of the United States?
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Yes
No
Are you at least 18 years of age?
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Yes
No
Please upload a copy of your state or government issued ID, Social Security Card or Work Visa, proof of covid vaccination and any other enrollment documents. If you are not able to upload them, please bring the documents with you on Mandatory Orientation day.
Is English your primary language?
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Yes
No
If English is NOT your primary language, have you taken any ESL (English as a Second Language) classes?
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Yes
No
Not applicable
Driver's License Number (no dashes)
*
Race (Required for Background Check
*
African-American
Asian
Caucasian
Hispanic/Latino
Native American
Pacific Islander
Mixed Race
Other
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State of Birth (Required for Background Check)
*
Country of Birth (Required for Background Check)
*
Social Security Number (Required for background check) *If you do not have a SSN, enter all 1's. You MUST have a SSN or Authorization to Work in the USA in order to take this CNA course!
*
How did you hear about Faith Healthcare Training Center?
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Friend
Family Member
Google Search
Social Media
Other
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Which Social Media platform do you use most often?
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Facebook
Instagram
Twitter
None
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Do you have a laptop or iPad? This course requires the use of a laptop or iPad for coursework. Students are required to bring their laptop or iPad to class each day
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Yes
No
No, but I will have one before the start of class.
Have you ever been convicted of a felony or any other crime?
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Yes
No
If yes, please include specific information including the date of felony charge, nature of felony, which court and final outcome. Submit copies of the court documentation is available
Court Documentation
Did you graduate from high school?
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Yes
No
Not applicable
High School Name / Graduation Date / City and State
*
Did you obtain a GED or equivalent education?
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Yes
No
Not applicable
Did you graduate from college?
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Yes
No
Not Applicable
College Name / Graduation Date / City and State
Do you have any physical condition(s) or any other condition(s) which would limit your ability to perform essential job-related functions?
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Yes
No
If yes, specify those restrictions or accommodations
Do you have a learning disability, IEP or 504 Plan? (This will allow us to assist you during the course)
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Yes
No
Please explain, if applicable
Why are you pursuing a career as a QMA?
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Emergency Contact Information
Emergency Contact Name
*
Emergency Contact Phone Number
*
QMA Application ($100 Deposit). This non-refundable fee covers the cost of your application, your pre-admission testing appointment and administrative fees.
*
QMA Electronic Application
$100
Register Now!
