HHA Training Registration Returning PECA Students

HHA Training Registration

PECA Student
Student Name

First NameLast Name
Date of Class

MonthDayYear
Date
Age
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Social Security Number
State Identification / Driver License Number
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever had an IEP or 504 Plan?
CNA License Information

License NumberCNA Training Program Completion Date
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.
File Upload

2x2 Colored ID Picture/birth certificate, social security card, Nurse Assistant Completion Certificate or CNA Certification, and medical clearance.
Upload
Health History
If the student have any allergies, please list them down below:
Does the student currently taking any medications? If yes, please list them down below:
Was the student previously hospitalized or undergo any surgery?
Does the student have any medical conditions that you would like to declare?

Immunization/Vaccination

	Vaccinated?	Year
Hepatitis B
Varicella
Tetanus
Measles
Mumps
Rubella
Polio
Diphtheria
Flu Vaccine
COVID 19 Vaccine
2-Step TB or Chest X-ray

Reminders
Students successfully completing the Home Health Aide course will be eligible for certification through the State of California Department of Public Health.

To participate in the clinical portion of the program the student will need to be fingerprinted and have a criminal background check completed along with the following.

COMPLETION OF NATP. All students must have completed 160 hours of training through an approved Nurse Assistant Training Program by the California Department of Public Health prior to the start of class. ORIENTATION. All students are required to attend orientation before starting the program. REQUIREMENTS. It is important to pass and complete all requirements before school starts. Failure to do so may delay the student from starting the program. MEDICAL CLEARANCE. The school required all students to have medical clearance from their doctor. BACKGROUND CHECK. Students who have been convicted of a criminal offense may not be eligible for certification (contact the office if this applies).
Student Signature

Clear
Parent/Guardian Signature (if under 18 years of age)

Clear
Date Signed

MonthDayYear
Date

My Products*

Registration Fee (Non-Refundable)The registration fee will hold your seat in the HHA Training Program. The registration fee is non-refundable, however, there are some cases refunds will be granted. Please see the refund policy for exceptions for refund. There is a 5% processing fee for all credit card transactions; it will be listed as tax. The remaining balance is due on or before the first day of class. All students must have all outstanding balances paid prior to entry of the class.

$325.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Type a question
This is to confirm the arrangement under which we will accept payment of your outstanding balance of $325.00 to be paid in full on or before the first day of class. By signing and submitting this form along with the $325.00 registration fee (non-refundable) indicates admission of the full amount of the account and acceptance of the terms of our agreement. If there is a default in making any payment, at our option, the full balance owing on the account, together with accrued agreed interest, shall immediately become due and payable and continue to accrue interest, before and after judgment, at the rate of 9% interest until paid off in full.

Yes, I agree
Should be Empty:

HHA Training Registration

File Upload

Health History

Reminders