Nursing Assistant Program Application

Nursing Assistant Program Application
Student Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
High-school graduation year
This is for financial aid, leave blank if you have not graduated
Please review the options below to select your preferred start date.
We offer the following class options: Evening Classes. Classes are held during the evening hours; however, students must attend two daytime clinical sessions (7:00 AM–3:30 PM) during the final week of the program. For detailed program information and a sample schedule, please refer to the student handbook.

Important Note: While we strive to accommodate all requests, class spots are filled on a first-come, first-served basis. Students who complete their enrollment in full will be given priority in securing their spots.
Evening Class Options 2026 (Mon-Fri 4pm-9pm with two 7am-3:30pm clinical days the last week) 3 Weeks Total
Evening Class Options 2025 (5pm-9:30pm with two 7am-3:30pm clinical days) 3.5 Weeks
ID Upload

Please upload a picture of a valid government identification (Drivers License, State ID, Passport) . (You can upload multiple pictures for front/back pictures)
File Upload

Cancelof
Completing this form does not guarantee acceptance. Visit the payment page to learn about financial options.
How did you hear about us?
What size scrubs would you need? (Our supplier has SM-5X)
I was referred by:
Refund Policy & Handbook:

You must review both our Refund Policy & Handbook. By signing below, you acknowledge that you have reviewed both the Handbook and the Refund Policy and agree to their terms.
Signature
Signature Date

MonthDayYear
Date
Signature
Evening Class Options 2025 (Mon-Fri 5pm-9:30pm with two 7am-3:30 pm clinical days) 3.5 Weeks
Should be Empty:

Nursing Assistant Program Application

ID Upload