CNA Application - $100 (Non-Refundable Fee)

IMPORTANT - Currently the long-term care facility (nursing home) whom we are partnered with is NOT requiring proof of receiving the Covid vaccination or an exemption. If the requirement changes, we will notify each student.

Which CNA class are you interested in attending? *

Maiden Name (If Applicable)

Are you at least 15 years of age? *

Yes

Gender *

Male

Female

Prefer not to answer

Are you a citizen of the United States? *

Yes

Is English your primary language? *

Yes

If English is NOT your primary language, have you taken any ESL (English as a Second Language) classes? *

Yes

Not applicable

Social Security Number (REQUIRED for background check) *You MUST have a SSN or Authorization to Work in the USA in order to take this CNA course! *

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.

Have you received the Covid Vaccination? *

Yes

Do you have proof of receiving the Covid Vaccination? *

Yes

Not Applicable

State of Birth (Required for Background Check) *

Country of Birth (Required for Background Check) *

Race (Required for Background Check *

Do you have a laptop, tablet or iPad? *This is REQUIRED* *

Yes

No, but I will have one before the start of class.

Which Social Media platform do you use most often? *

How did you hear about Faith Healthcare Training Center? *

Have you ever been convicted of a felony or any other crime? *

Yes

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 (if applicable)

Did you graduate from high school? *

Yes

Not applicable

High School Name / Graduation Date / City and State

Did you obtain a GED or equivalent education? *

Yes

Not applicable

Did you graduate from college? *

Yes

Not Applicable

College Name / Graduation Date / City and State (if applicable)

Do you have a learning disability, IEP or 504 Plan? (This will allow us to assist you during the course) *

Yes

Please explain, if applicable

Do you have any physical condition(s) or any other condition(s) which would limit your ability to perform essential job-related functions? *

Yes

If yes, specify those restrictions or accommodations

Why are you pursuing a career as a Certified Nursing Assistant? *

Emergency Contact Information

Emergency Contact Name *

Emergency Contact Phone Number *