CNA GNA Application
Are you currently receiving any of the following benefits?
Food Stamps
TCA
Foster Care
Today's Date
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Month
-
Day
Year
Date
Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Gender
Male
Female
I prefer not to answer
Race/Ethinicity
Hispanic/Latino
African American
White/Caucasian
Asian
American Indian/Native Alaskan
Native Hawaiian/Pacific Islander
Emergency Contact Name
First Name
Last Name
Emergency Contact Relationship
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about It Works Learning Center?
Which training are you interested in?
CNA
GNA
PCT
Other
Have you ever applied for enrollment to an It Works course before?
Yes
No
Do you have any outstanding State of Maryland Tax Liens?
Yes
No
If yes, how much?
Do you have a valid government issued picture ID?
Yes
No
Do you have your original Social Security Card?
Yes
No
Do you have a Birth Certificate, Passport or proof of address?
Yes
No
Do you have a Permanent Resident/Green Card or I-94? (foreign born)
Yes
No
If yes, which one?
Did you previously have your CNA or GNA license?
Yes
No
If yes, explain.
Do you have a High School Diploma or G.E.D.? (Not required)
Yes
No
Do you receive benefits from DSS (Food Stamps, TCA)?
Yes
No
If yes, please provide CID#
Due to COVID-19, all classes are held virtually until further notice. Do you have access to a computer and internet access so that you can participate in online courses?
Yes
No
When are you Working or in School? Identify times/shifts:
Identify all appointments that may prevent you from attending class:
If enrolled in this class, will you be able to attend ALL weeks of class?
Yes
No
Signature
If enrolled in this class, will you accept full-time employment for at least 1 year?
Yes
No
Signature
When do you want to work?
Days 7am-3pm
Evenings 3pm-11pm
Nights 11pm-7am
Full-time
Part-time
Weekend
PRN
Please list information for all schooling including high school, technical school, and college. Include school names, addresses, degrees, and graduation dates.
Are you willing to submit for a drug screen, which includes marijuana or THC use in the last 90 days?
Yes
No
Have you ever been arrested, charged with a crime, listed as a defendant or discussed your case with a judge?
Yes
No
If Yes, explain ALL instances, noting state and year of occurrence(s), charges (misdemeanor or felony), status/outcomes(Pending, Warrant, Guilty, Not Guilty, Probation Before Judgement (PBJ), STET, Nolle Prosequi (Nol Pros), etc.), and relevant details, including ALL expunged records, regardless of location, age, date or relevance. Include traffic charges, but not parking tickets. Include the state, date, charges, outcome, and details.
PROGRAM REQUIREMENTS: PROFESSIONALISM: Students must be willing to learn, able to work on a team and have a focused and committed demeanor, including appropriately exhibited attitude, behavior, class participation, attention to timeliness/lack of tardiness, good communication skills, work ethic and people skills. PHYSICAL ABILITIES: Students will be required to meet the same physical demands as are required by employees of a nursing home. This includes intermittent and even prolonged physical activity, such as walking,standing, sitting, and lifting as much as 50 lbs. or more. If you have any pre-existing condition that may prevent you from performing any skills or activities required of students attending this program, written verification must be provided from your physician, stating that there are “no activity restrictions.” HONESTY: Students need to possess strong integrity and trust. Lying, cheating, stealing or other dishonest or unacceptable behavior will not be tolerated and are grounds for immediate removal from this program. ATTENDANCE: A minimum of 90% attendance is required for the classroom lecture and skills. You must attend all 100% of the 40 hours of clinical rotation. Lateness will be factored into attendance. GRADES: All classroom modules must be completed with an average score of 80%. A score of 80% or better must be achieved on the final exam. OTHER: All obligations to grant, funders, and It Works Learning Center, Inc. must be met.
Prior Work Experience (Begin with your most recent employer. If unemployed, write Unemployed.) Include employers name, address, phone number, start date/end date, pay rate, position/title, supervisor, and reason for leaving.
I understand that, if I am accepted into this training program, false statements on this application or providing falsified documents will be considered sufficientgrounds for my declination or removal. I understand and agree that my acceptance into this training program is contingent upon a satisfactory criminalbackground check. I further understand that a drug screen may be conducted, and a positive test will automatically disqualify me from consideration for thisprogram.I hereby authorize It Works Learning Center, Inc. and its agents to contact any and all corporations, former employers, educational institutions, lawenforcement agencies, city, state, county and federal courts and military services to release information about my background, including, but not limited to,information about my employment, education, driving record, criminal record, and general public records history. I consent to the release of this applicationand all other information, documents and agreements that I provide to or enter into with It Works Learning Center, Inc. to the facility hosting the training,and, if different, the employer where I am seeking employment, as well as any source of my tuition. I consent to photos being taken of me and used in promotionaland marketing materials, for which I will receive no compensation. Following completion of this training program, I furthermore consent to the release of myemployment information by my employer to It Works, to include my hire date, pay rate and, if applicable, separation date and reason. I release the aforesaidparties from any liability and responsibilities for collecting or sharing the above information. I believe to the best of my knowledge that all information I haveprovided is accurate, true and correct.
Print Name
Date
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Month
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Day
Year
Date
Submit
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