2021 CNA/HHA Work Ready Program

2021 CNA/HHA Work Ready Program
Name

First NameLast Name
Email
example@example.com
Are you at least 18 years or older?

YesNo
Do you have a High School Diploma or GED?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
E-mail
Attach your Resume (optional)

Upload a File

Cancelof
How did you hear about Life Community Center CNA Work Ready Program?
Do you attend Life Church?

YesNo
Do you participate in Life Community Center activities? (Food pantry, Imagine Christmas, Raptime family)?

YesNo
Why do you want to participate in the CNA program?
What steps will you take to be successful in this program?
Tell us about a time you faced a challenge. What did you do to overcome that challenge? What was the result of the action you took?
Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony relating to social and economic assistance, relating to fraudulent practices, relating to drug abuse prevention and control or a similar felony offense(s) in any state or jurisdiction?

YesNo
If the above question is yes, how long ago? Please provide information.
Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony relating to controlled substances?

YesNo
If the above question is yes, how long ago? Please provide information.
Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felon relating to public health, welfare, Medicare and Medicaid issue?

YesNo
If the above question is yes, how long ago? Please provide information.
Have you ever been terminated for cause from the Florida Medicaid Program, even if reinstated?

YesNo
If the above question is yes, how long ago? Please provide information.
Have you ever had disciplinary action taken against your certification to practice any healthcare-related profession, been denied, or surrendered a certification to practice any healthcare-related profession in Florida or in any other state, jurisdiction or country?

YesNo
If the above question is yes, how long ago? Please provide information.
Have you EVER been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense?

YesNo
If the above question is yes, how long ago? Please provide information.
In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery program or impaired practitioner program; or, admitted or referred to a hospital, facility or impaired practitioner program for treatment of a diagnosed mental disorder or impairment?

YesNo
If the above question is yes, how long ago? Please provide information.
Thank you for your submission. We will notify you if you have been selected to move to the next phase. If you have any questions, please don't hesitate to reach out to us at 813.994.0685.

Have a blessed day!
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