A-List Healthcare Training Academy CNA Program Pre-Enrollment Form
To be eligible for the CNA training course candidates must be at least 17 years of age or older, have a valid government issued ID such as a drivers license or state ID, must have a negative TB skin test or chest X-ray, and be able to pass a criminal background check. Individuals under 18 years of age must provide parent/guardian information and have their consent. Please email TB test results, immunization records and CPR certifications(if available) to info@alisttrainingacademy.com.
What cohort are you interested in?
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Please Select
03/17-04/16 TUE/WED/THUR (4:30pm-9:30pm)
05/18-05/29 MON-FRI (08:30am-4:30pm)
06/01-06/12 MON-FRI (08:30am-4:30pm)
Name
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First Name
Middle Name
Last Name
Suffix
Date of Birth
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-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Social Security Number
*
Driver License Number or State ID Number
*
Emergency Contact '
*
First Name
Last Name
Relationship of Emergency Contact
*
Emergency Contact Phone Number '
*
Please enter a valid phone number.
Do you hold a High School Diploma or GED?
*
Please Select
Yes
No
Do you hold any Associate's or Bachelor's Degrees?
*
Please Select
Yes
No
Last School Attended
*
Graduation Date
-
Month
-
Day
Year
Date
If you are younger than 18 years of age, please provide the name of your parent/guardian
First Name
Last Name
Parent/ Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which class are you interested in joining -
*
Please Select
In person
Hybrid Online
Have you been convicted of a crime?
*
Please Select
Yes
No
Please be aware that all candidates will have a criminal background check completed.
If you have answered yes to the previous question, please explain.
Do you have access to Technology?
*
Smartphone
Computer
Tablet
None
Do you have any physical or cognitive limitations that may effect your duties as a nursing assistant? if yes, please explain.
*
Please tell us why you are interested in this program
*
What are your career goals after completing this program?
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Upon course completion, would you be interested in employment with one of our clinical partners.
*
Please Select
Yes
No
I do know yet
Do you have a work shift preference?
*
Morning
Afternoon
Nights
Part Time
Full Time
Contingent
No preference
How would you be paying your tuition?
*
Please Select
Self Pay
Mi Works!
Mi Achievement Skills Scholarship
Employer Sponsorship
Other Sponorships
For non-private pay candidates ONLY! please provide your uniform size
Please indicate the contact information for agency whom will pay your tuition. Provide Agency name, name of contact person, phone number and/or email address.(Optional)
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Please upload your most current resume.
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Please upload a copy of you governmental ID (Driver's License, State ID or U.S. Passport)
*
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I attest that all information disclosed is correct. I authorize A-List Healthcare Training Academy to use pertinent information provided on this form to determine eligibility for enrollment and I acknowledge the required application fee is non- refundable. I understand that a background check will be performed in order to consider each candidate for enrollment. Place your signature below if you consent to a background check.
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I understand that after completing this course, I must register for the Headmaster TMU certification exam for which is an additional $175.00 to be paid directly to that entity. I also understand that once I have successfully passed the certification exam, I must pay the state of Michigan $40.00 for the initial certification and $40.00 every two years for the renewal period.
*
I agree
By enrolling in a course at A-List Healthcare Training Academy, I acknowledge and agree to the following terms regarding financial responsibility: I understand that I am responsible for paying the full tuition amount associated with the course, including any non-refundable fees such as the application fee, administrative fees, or processing charges, as outlined in the course information provided at the time of enrollment. By signing below or submitting my enrollment electronically, I agree to the terms listed above and accept full financial responsibility for all tuition and fees incurred as part of my course enrollment.
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I agree
Signature
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Your signature indicates all information is correct and you authrorize A-List Healthcare Training Academy’s administration department to perform a criminal background check.
How did you hear about our program?
*
Friend/Family
Social Media
Searching the Web
Flyer/business card
Other
Name of Referring Person
First Name
Last Name
My Products
*
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Enrollment Fee (Non Refundable)
Applications will not be processed until enrollment fee is complete. Please contact us at 248-840-9103 before making necessary payment to ask any questions.
$
100.00
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