DHEC Fredericksburg Medication Aide Course Registration Form

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During the COVID-19 Pandemic we too are doing our part to ensure we are using safe practices and following the guidelines mandated by the state and the Virginia Board of Nursing. We are fortunate to be one of few schools in Virginia to have structured online classes that were approved by the Virginia Board of Nursing before COVID-19. With that said, all classes for 2021 will be online. The safety of our students, and staff are our main priority. If we experience a spike in COVID cases, our contracted facilities may delay clinical rotations as a preventative measure to protect the well being of their residents. We will notify students as soon as possible. Please keep in mind it's the decision of the facility and not DHEC. DHEC will delay clinicals if we feel its unsafe for our staff and students. Please sign your name indicating you have read and understand this message. * This field is required.
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WE DO NOT ACCEPT TEMPORARY CNA CERTIFICATES FOR OUR MEDICATION AIDE COURSE. WE ONLY ACCEPT PCA AND DCA CERTIFICATES (BOTH WILL BE VERIFIED). WE ACCEPT NURSE AIDE CERTIFICATES FROM VIRGINIA BOARD OF NURSING APPROVED NURSE AIDE PROGRAMS ONLY
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EFFECTIVE SEPTEMBER 2021, ALL NURSE AIDE AND MEDICATION AIDE STUDENTS ARE REQUIRED TO BE FULLY VACCINATED (COVID-19) BEFORE THE START OF CLASS. WE WILL CHECK THE VALIDITY OF ALL VACCINATION CARDS. Please sign your name indicating you read and understand this message.* This field is required.
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Please upload your COVID-19 vaccination card. We will check the validity of each card. If you have not received the vaccination, please be prepared to present your proof of vaccination on the first day of class. Click next if you do not have a card to upload at this time.
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ALL APPLICANTS MUST BE ABLE TO READ, WRITE, SPEAK, AND UNDERSTAND ENGLISH FLUENTLY. Do you read, write, speak and understand English fluently?* This field is required.
YESNO
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Student Name* This field is required.
First Name
Middle Name
Last Name
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Birth Date* This field is required.
Month
Day
Year
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Social Security Number* This field is required.Needed for background check
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Upload a copy of your government issued ID* This field is required.Drivers license, passport or student ID
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Gender* This field is required.
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N/A
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Address* This field is required.
Street Address
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Student E-mail* This field is required.*** PLEASE DO NOT USE WORK OR SCHOOL EMAIL ADDRESSES ** THESE EMAIL ADDRESSES ARE OFTEN BLOCKED BY FIREWALLS
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Phone Number* This field is required.
Area Code
Phone Number
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Are you a former DHEC student?
YESNO
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Have you ever been convicted of threatening another person, assault, battery, or theft?* This field is required.
YESNO
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Have you ever been charged with a misdemeanor?* This field is required.
YESNO
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Have you ever been convicted of a felony?* This field is required.
YESNO
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If you are a convicted felon OR if you have been charged with theft, threatening another person, assault or battery, you will have to submit supported documents as requested by the Virginia Board of Nursing, when you register for your state boards ** Please note: we complete a criminal and sex offender background check on all enrolled students**
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Emergency Contact Name * This field is required.
First Name
Last Name
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Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
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Emergency Contact's Relation to the Student* This field is required.
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In case of an emergency, do you have any medical conditions we should be aware of?* This field is required.
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How did you hear about us?* This field is required.
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Please choose class start date
10/31/22 - 12/2/22
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Medication Aide students are required onsite once a week for skills sessions and/or clinicals. Please select your preferred skills sessions.* This field is required.Tuesdays only!!!! Skills lab is Week 2 @ the school 10am - 1pm / Clinicals are Weeks 3 thru 5 @ Clinical Site 6:30 - 12 noon.
Tuesdays only!!!! Skills lab is Week 2 @ the school 10am - 1pm / Clinicals are Weeks 3 thru 5 @ Clinical Site 6:30 - 12 noon.
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ONLINE MEDICATION AIDE STUDENTS ONLY : Students are required on campus the first week of class for skills practice. This practice will be on Thursday from 4:00pm - 8:00pm. Please initial to acknowledge you have read this. If this does not apply to you please write n/a. DUE TO COVID-19 THIS SCHEDULE WILL BE FLEXIBLE WHEN WE ARE ABLE TO SAFELY HOLD SKILLS LAB, WE WILL HAVE AN EVENING CLASS AND DAYTIME CLASS FOR SKILLS LAB.* This field is required.
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* This field is required.Please upload a picture of your PCA , Nurse Aide , or CNA certificate. We will verify all certificates. If we are unable to verify your certificate, your enrollment will be cancelled. **WE DO NOT ACCEPT TEMPORARY CNA CERTIFICATES**
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Why did you decide to become a Medication Aide?* This field is required.
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Select Scrub Top Size -We provide our students with one white scrub top. Students are responsible for purchasing their own scrub pants Medication Aide students wear burgundy/wine scrub pants.. * This field is required.
XS
Small
Med
Large
XL/1x
2x
3x
4x
5x
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10- Panel Drug Test and Random Drug Test done(including marijuana) @ DHEC and /or clinical site discretion. If the applicant fails drug test he/she will be dropped from their course immediately. No Refund will be issued. Please initial* This field is required.
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Nurse Aide / Medication Aide applicants must have PPD completed prior to clinicals. Please initial. If you are enrolling for PCA please write n/a* This field is required.
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Tattoos must be covered during clinicals. Some exceptions apply per instructor. Please initial* This field is required.
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Nails must be kept short(no more than 1/2 inch long)No bright colors. No embellishments. Please initial* This field is required.
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Makeup and eyelashes must be natural looking. Eyelashes must be natural length. Please initial* This field is required.
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No facial piercings during clinicals. Please initial* This field is required.
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For clinicals, your hair must be the color that you or another person could be born with (blacks, browns, blondes, brunettes, natural reds. Gray hair is acceptable, of course! Please initial * This field is required.
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When in uniform, no headscarves or wraps(unless for religious purposes), no caps or hats. Please initial.* This field is required.
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The school reserves the right to deny admission based on information obtained from the criminal background check. If admission is denied the applicant is entitled to a full refund. Please initial* This field is required.
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Please enter your initials to acknowledge your $350 deposit or $350 of your full payment is nonrefundable. If an applicant wishes to change their enrollment to the next class, the applicant must provide a written transfer notice (email accepted) at least 7 business days before the start date of the class they are currently enrolled. Otherwise, the $350 deposit will be non-transferable. Students are allowed one class transfer only. Please initial * This field is required.
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Cancellation- To receive a refund of tuition payments (this does not include the non-refundable $350 deposit) the applicant must provide the school with a written notice of cancellation (email accepted) at least 7 business days(this does not include the weekend) before the start date of the class they are currently enrolled. Otherwise, the applicant will not be eligible for a refund of tuition payments. In verified emergencies, the school will allow the applicant to transfer to the next class. Please initial* This field is required.
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No Call No Show - Applicants who are a no call no show on the first day of class or other scheduled days of class will be dropped from the class. No refunds will be issued and the applicant will be responsible for any unpaid balances. Please initial * This field is required.
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Tuition Payment- If tuition payments are not received on or before the due date, the student will be dropped from the class. If a student is dropped for nonpayment, no refunds will be issued and the student is responsible for any unpaid balances. Please initial* This field is required.
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All payments ($350 deposit and any missed payments) are due at time of registration. Please return to our website to look at payment deadline dates or call the school, if you are unsure. We will not process your registration without full payment due. Please initial.* This field is required.
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Is someone else using their credit card to register the student for class? If so, please provide credit card owners First and Last Name, Address and Phone Number. If not, please write N/A* This field is required.
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In an effort to protect against fraud, If cardholder is not the student, please upload cardholders drivers license.
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Please read and sign- By signing this contract you agree that all information provided is true, accurate, and complete. You agree to the payment terms of this contract. You agree if you are dropped from this class for not making your required payments, on the due date, you will not be eligible for a refund of any money paid towards the tuition. You will also be responsible for the remaining balance. If you choose to withdraw, after the start date, you will still be responsible for any remaining payments owed. If you do not pay the remaining balance within 30 days, your account will be forwarded to collections. You agree to all terms of this Agreement, including, but not limited to, the Electronic Payment Authorization, Recurring charges authorization(if you have elected to pay by recurring electronic funds transfers), when you sign this Agreement. By signing this agreement, you acknowledge you are the cardholder or have permission to use the credit/debit card used at time of registration PLEASE SIGN YOUR FULL NAME* This field is required.
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Select tuition option and past due payment options. Please be sure to include any past due payments. If you only submit the deposit, your registration will not be processed until all payments due are received. We will not hold your registration. PLEASE SCROLL THROUGH THE COURSES BELOW TO FIND THE COURSE YOUR DESIRED COURSE* This field is required.You must make all payments on time to avoid being dropped from the class. If you do not make your payment by the due date , you will be dropped from the class. No exceptions. We will not grant extensions.
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ORDER SUMMARY
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Online Medication Aide Full Payment ($350 non-refundable) - ONLINE ONLY
$650.00+Edit
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Online Medication Aide Course Deposit (Non-Refundable) - ONLINE ONLY
$350.00+Edit
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Past Due Medication Aide Payments
$100.00+Edit
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