UWA-CNA Training Program Application

UWA-CNA Training Program Application

This form serves as your application to the UWA Certified Nursing Assistant Training Program. It is important to be truthful. Dishonest answers may be grounds for dismissal from the program. If you have ANY questions, you may contact program staff at blackbeltahec@uwa.edu, 205-652-5494, or 205-652-3829.
Name and Contact Information
Name

First NameLast Name
Primary Phone Number
Please enter your primary phone numberFormat: (000) 000-0000.
Alternate Phone Number
Please enter an alternate phone number where we can reach you if we're unable to reach you at your primary number. Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Eligibility Factors

All applicants must be 18 and older and out of high school. Other factors may impact eligibility, but no other single factors exclude applicants from consideration. Eligibility is officially determined by the Demopolis Career Center, (334) 289-0202.
Age (must be 18 and older to be eligible)
Date of Birth

MonthDayYear
County of Residence
County, State (Example: Sumter County, AL)
Do you receive public assistance?
Are you pregnant or parenting?
Are you currently enrolled in High School or an Institute of Higher Education (College/University)? Currently enrolled students are NOT considered eligible.
Household Information

If you are 19 and older, you are considered a household of 1 unless you are married (filing joint taxes) and/or have children.
Marital status
Total number of individuals in household:
Applicant number of children:
Total household income (last 6 months):
Education
Highest Grade Completed
H.S. Diploma
G.E.D.
Certification or Degree
U.S. Citizenship
United States Citizen
Selective Service
If you're not a US Citizen, are you authorized to work in the United States?
Employment

Please answer these questions to the best of your ability. We will NOT contact your employer.
Are you currently employed?
Employer Name
If unemployed, type "NA."
Job Title
If unemployed, type "NA."
Start Date
If unemployed, type "NA."
Hourly Pay
If unemployed, type "NA."
Hours Worked Per Week
If unemployed, type "NA."
Other Information
Have you ever been convicted of a felony? A felony does not automatically disqualify you, but does help us assist you.
If yes, please explain.
Disability Disclosure: Applicants with disabilities or any other barriers to employment are encouraged to self-disclose their disability in the space provided below. This information is voluntary and is for reporting purposes only. All information will be kept confidential and will not be subject to any adverse treatment. Information will only be used in accordance with the law.
If yes, what accommodations do you require?
Ethnicity/Race
Gender
Primary Language
Questions
Why do you want to become a Certified Nursing Assistant? How can we help you achieve this goal?
Do you have any questions? We're happy to answer them! Please type any questions you may have here.
Signature
Signature - By signing, you certify that your answers are true and complete to the best of your knowledge.
Thank you!

Thank you for your interest in the UWA CNA Program! After you submit your application, a member of our staff will be in touch with you. If you have ANY questions, please feel free to contact blackbeltahec@uwa.edu, 205-652-5494, or 205-652-3829.
Should be Empty:

UWA-CNA Training Program Application

Name and Contact Information

Eligibility Factors

Household Information

Education

U.S. Citizenship

Employment

Other Information

Questions

Signature

Thank you!