ETA - Applicant Questionnaire

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Your Future in Healthcare Starts Here

Do you love helping others? Have you cared for family members or always dreamed of a healthcare career? This is your chance to turn that passion into a profession!

We’re selecting 6 to 12 students for our Nursing Assistant Training Program (NATP), which is licensed by Rhode Island’s Department of Health (NATP00162).

📍 Hands-on training at top facilities in Rhode Island!
🚀 Fast-track your career and make a real impact!
💰 Scholarships are available to help reduce the cost!

Spots Are Filling Fast – Apply Today!
Many of our students started just like you—motivated to help others but unsure where to begin. Whether you’ve cared for a loved one, want to make a difference, or are ready for a career change, we’re here to support you every step of the way.

📢 Complete this quick form NOW to secure your spot!
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Name* This field is required.
First Name
Last Name
4
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
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Republic of the Congo
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Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Samoa
San Marino
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Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
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Slovakia
Slovenia
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Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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Sudan
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eSwatini
Sweden
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Tajikistan
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Thailand
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Other
Country
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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How did you hear about us?* This field is required.
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What is your current occupation?* This field is required.
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Have you applied to Empower Training Academy before?* This field is required.
YESNO
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What program did you apply for and why didn't you participate?* This field is required.
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What is your education level?* This field is required.
I do not have a high school credential.
High school diploma or equivalent
Some college credit
College degree
Other
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What is your country of origin?* This field is required.
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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We would like to see if you qualify for any programs that help cover the cost of this program. Are you currently receiving TANF benefits (cash assistance and SNAP) from DHS?* This field is required.
Please Select
Please Select
Yes
No
Prefer not to answer
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Can you commit to our Monday-Thursday classes from 9 AM to 1 PM for 20 days?* This field is required.For the first 20 days of the program, you’ll attend lab classes Monday-Thursday from 9 AM - 1 PM, where you’ll practice essential nursing assistant skills in a hands-on setting.
YESNO
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Can you commit to Monday-Thursday afternoon classes?* This field is required.
YESNO
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Can you commit to our one-week clinical training, running Monday through Friday from 7 AM to 3:30 PM?* This field is required.After completing your 20 days of classroom training, you’ll spend one week (Monday through Friday, 7 AM—3:30 PM) gaining hands-on experience at a skilled nursing facility in East Providence, RI.
YESNO
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Do you speak, read, and write English* This field is required.
YESNO
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Are you at least 16 years of age?* This field is required.
YESNO
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Can you provide a legal picture ID as proof of your identity?* This field is required.
YESNO
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Can you provide a copy of your social security security card?* This field is required.
YESNO
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Are you vaccinated for COVID-19?* This field is required.
YESNO
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If accepted to our training program, are you willing to get your COVID-19 vaccination?* This field is required.
YESNO
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Have you received your seasonal flu vaccination?* This field is required.
YESNO
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If accepted to our training program, are you willing to get your seasonal flu shot?* This field is required.
YESNO
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Can you provide proof of a valid exemption for not taking your seasonal flu shot?* This field is required.
YESNO
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Can you provide proof of MMR, Tdap, and Varicella* This field is required.You can obtain proof of your MMR, Tdap, and Varicella immunizations by requesting a copy of your immunization record from your healthcare provider. You may need blood tests to confirm your immunity if you cannot locate your immunization records.
YESNO
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Are you willing to complete a 2-step PPD or a chest X-ray or provide proof for this program? * This field is required.
YESNO
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Do you have a doctor’s physical from the past year confirming no physical limitations, or can you get a doctor’s note clearing you for this program? * This field is required.You must have had a doctor’s physical exam within the last year or obtained a note from a physician confirming that you can participate in the program.
YESNO
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Do you understand you must pass the Rhode Island (RI) Bureau of Criminal Investigation (BCI) check for this program?* This field is required.To be eligible for the program, you must pass a criminal background check conducted by the Rhode Island Bureau of Criminal Investigation (BCI).
YESNO
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What inspired you to pursue a career as a nursing assistant, and what are your long-term goals in the healthcare industry?* This field is required.
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What challenges do you anticipate facing during the nursing assistant training program, and how do you plan to overcome them?* This field is required.
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Ok
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Is there anything else you'd like to share?* This field is required.
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Sorry...

To be eligible to participate in Empower Training Academy’s Nursing Assistant Training program, you must meet the following requirements:

✅ Attend all lab sessions (Monday-Thursday, 9 AM - 1 PM for 20 days)
✅ Attend all clinical training (Monday-Friday, 7 AM - 3:30 PM for one week)
✅ Be at least 16 years old
✅ Provide a valid ID and Social Security card
✅ Be COVID-19 vaccinated
✅ Provide proof of MMR, Tdap, and Varicella immunization
✅ Provide proof of seasonal flu shot (Oct-May)
✅ Pass the RI BCI Check with fingerprinting
✅ Speak, read, and write English

If you made an error, please select the previous option. If not, please reapply when you meet the requirements.
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