Student Registration Form

Institute of Caring

(812) 584-1555

vanessa@instituteofcaring.com

www.instituteofcaring.com
- Full Name*
  
  First NameMiddle NameLast Name
- Social Security Number*
  e.g. 11183021
- Program of Interest*
- Email*
  Watch your email! We communicate often via email :)
- Phone Number*
  Preferred for call/textFormat: (000) 000-0000.
- Emergency Contact*
  
  First NameLast Name
- Relationship*
  ex. Father, Mother, etc.
- Phone Number Of Person To Contact In Case Of Emergency*
  Please enter a valid phone number.Format: (000) 000-0000.
- Permanent Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip CodeCountry
- Current Employer Name*
- Current Supervisor Name*
- Current Supervisor email*
- Upload a copy of Drivers License/ID, current PPD, current physical, CNA certification (for QMA students)*
  
  File should be in pdf, doc/docx format.
  Cancelof
- Upload a GED/High School Diploma. (QMA applications will not be processed without this)
  
  File should be in pdf, doc/docx format.
  Cancelof
- You require a need for accomadation for reading, writing or comprehension. Needed for testing purposes. Please provide IEP copy.Has any disciplinary action ever been taken against you regarding any health license, certificate, registration or permit you hold in any state?You have pending criminal charges other than minor traffic violations?You have had any allegations or charges for neglect or abuse of a dependent.Other special circumstances that need to be discussed (please specify below)
- Other: Please explain
- 210518756951895
- 37404528
- 37578465
- 42404828
- The fastest growing segment of the population in the United States is the elderly. Because of the medical advances they are living longer. Certified Nursing Assistants provide most of the direct personal care to the elderly residents. A CNA helps in feeding, bathing and dressing residents, as well as many other tasks. The CNA can be the resident's best friend.
- Young AdultsElderlyChildrenMiddle Aged
- NurseCNAPhysicianFamily
- What are you most interested in getting from this education? Why are you wanting to explore a career in health care?
- YesNo
- In consideration of allowing me to participate in training, I, the undersigned participant (or parent/legal guardian if a minor) do hereby waive liability, release, and forever discharge the Institute of Caring, LLC, and any of each of their affiliates, officers, agents, employees, and representatives from any and all claims, demands, rights, and causes of action, of whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property and the consequences thereof, including death, resulting from my voluntary participation in the training. I have voluntarily and knowingly agreed to participate in the training and do hereby assume all responsibility for my participation in the training. I have voluntarily and knowingly agreed to participate in the training and do hereby assume all responsibility for my participation and activities in such training.*
  
  I agreeI disagree, and withdrawl participation in the program
- The Institute of Caring training program does not discriminate because of age, disabled, race, color, national origin, religion, sex, disability or being a qualified disable veteran or qualified veteran or the Vietnam era or other category protected by law. I hereby affirm that the information provided on the application is true and complete. I understand that any false or misleading representation or omissions made on the application may disqualify me from the training program. I hereby authorize persons such as the Institute of Caring, my employer, and other organizations to provide requested information regarding my application, and I completely release all such persons or entities from any and all liability related to the providing and use of such information. I understand if selected for the Institute of Caring training program, I will be required to submit to a drug screen prior to the commencement of clinical, if required by the clinical site. I understand if selected I may be removed at any time from the training for any reason with or without notice/cause.*
  
  I understandI do not understand
- By signing this acknowledgement form, I confirm that I have read the information and policies of the program. Any questions I had have been answered. I agree to comply with the information and policies and have received a copy of them as well as the well as the course outline. I further acknowledge that I am physically and mentally capable to performing the tasks required to complete the training program and any modification request documentation has been provided. I also understand failure to comply with these policies may result in my removal from the Institute of Caring's Training Program and possible future opportunities to participate.*
  
  I agreeI do not agree and choose to withdraw my application
- YesNo
- Signature
  
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