Enrollment Agreement

Phone: 706-850-4017 | Fax: 706-850-4015 | www.onebreathcna.com
Enrollment Agreement
Start Date

Month Day Year
Date
Estimated Graduation Date

Month Day Year
Date
Classroom meeting days and times: DAYS (8-5) NIGHTS (5:30-10) WEEKENDS (8-5) (circle one)

I understand that upon acceptance by One Breath CNA LLC, this document constitutes a legal and binding contract. I am applying for admission in the program and will receive a certificate of completion in that program upon graduation.
Initial Here

Clear
Total Number of Weeks: 6 Total Hours: 104 Externship Hours: 24
First Name *
Middle Name
Last Name
Name of Emergency Contact:
Relationship of Emergency Contact:
Emergency Contact Phone Number

Area Code Phone Number
Referral Source
SSN
Email *
example@example.com
Phone Number *

Area Code Phone Number
Date Of Birth

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
REGISTRATION FEE............ $50.00
Tuition.................................... $1000.00
Books, Blood Pressure Kit, State Exam, Et Al.... $1100.00
TOTAL COST........................ $2150.00
I will be paying the total amount due by

Debit Credit Money Order
I understand that One Breath CNA LLC offers job placement assistance, but does NOTguarantee a job or a starting salary upon graduation. (Initial Here)

Clear
I have read and accept the Enrollment Terms of this agreement. (Initial Here)

Clear
I hereby authorize One Breath CNA
LLC to obtain a copy of my latest background
check.
Student Signature

Clear
Enrollment Date:

Month Day Year
Date
Acceptance Date:

Month Day Year
Date
Type Full Name
Enter Student ID
Date

Month Day Year
Date
Should be Empty: