CNA/QMA Course Registration Form

Cardinal School of Care

CNA and QMA registration form. May 2025 Registration Closed
Student Name*

First NameMiddle NameLast Name
Preferred Name:*
This will be printed on your Student Badge
Birth Date*

MonthDayYear
Gender
Social Security Number:*
Required by State of Indiana to process your test application
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail*
example@example.com
Mobile Number*
Emergency Contact Needed
Name:Name* .
Number: Phone Number (with area code)*
Have you graduated from high school? (must have diploma OR GED for QMA course)*

YesNo
Do you have a GED?*

YesNoN/A
Are you at least 18 years old (must be for QMA course)?*

YesNo
Have you ever been convicted of a felony?*

YesNo
If yes, please list
Please select the course you would like to attend *
Can you commit to required class hours?

YesNo
Have you been licensed before or in any other state?*
If in another state, please list state.
I understand that the Indiana State testing fee is a separate fee, NOT included in the course fees.*

Yes, I understand
How did you hear about us?*
I certify that all answers given in this application are accurate to the best of my knowledge. I understand that failure to disclose or falsifying information could result in my dismissal from the CNA/QMA course. *

Clear
Registration Fee is required to reserve your seat and is NON-REFUNDABLE. The remaining balance must be paid in full prior to clinical/practicum. Failure to do so will result in a delay in receiving your certificate. We do have a coupon code available if you are in need or will qualify for IMPACT, please call us at 260-433-9426 to discuss.

Registration Fee*

CNA Registration Fee4% online processing fee will be applied. Cash price is $800.

$208.00

CNA Full Course Fee - AfterPay Option4% online processing fee will be applied. AfterPay Option

$832.00

QMA Registration Fee4% online processing fee will be applied. Cash price is $1300.

$308.00

Insulin Course (Paid in Full)4% online processing fee will be applied

$312.00

QMA Full Course Fee - AfterPay Option4% online processing fee will be applied. AfterPay Option

$1,352.00 Quantity

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

Should be Empty:

Cardinal School of Care

Payment Methods