School Application Form

Nursing Assistant Program Application

Alliance Specialty Healthcare Services, LLC
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Gender*

MaleFemale
Race*
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Virtual Equipment Checklist*

Please select uniform size*
How did you hear about us?*
If other was selected above, please specify:
Acknowledgment
I acknowledge that I will be participating in a virtual/blended learning program. I understand that I will read the student policy handbook in PDF format, sign the signature page and abide by it. I confirm that I will be responsible for providing the equipment needed for virtual or distance learning. I accept that all activities, work, and exams will be graded. I also understand that if I haven't received the covid vaccination and don't intend to, I must obtain a medical exemption from a physician to attend clinical.
1.) Please upload completed background information disclosure form (BID form). Link is located on website; click on the menu tab. You must save the document in your computer after filling it out; once completed, upload it below by clicking "Browse Files". Please be honest about criminal history when completing this form.

2.) Upload picture of government issued ID (front & back) REQUIRED

MAS students: school ID is acceptable
File Upload*

BID Form
Cancelof
Signature*

Clear
Date Signed*

MonthDayYear
Date
Parent/Guardian Signature

Clear
Required if under age 18
Should be Empty:

Nursing Assistant Program Application