CNA Training Registration PayLater with PayPal

CNA Training Registration
Student Name

First NameLast Name
Date of Class

MonthDayYear
Date
Are you under the age of 18?

YesNo
Age
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Social Security Number
CA Driver's License or Identification
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Information
Parent/Guardian's Name - Primary (if under 18 years of age)

First NameLast Name
Parent/Guardian's Phone Number
Please enter a valid phone number.
Parent/Guardian's Occupation
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.
Health History
If the student have any allergies, please list them down below:
Does the student currently taking any medications? If yes, please list them down below:
Was the student previously hospitalized or undergo any surgery?
Does the student have any medical conditions that you would like to declare?
Reminders
Students successfully completing the Nurse Assistant course will be eligible for certification through the State of California Department of Public Health.

To participate in the clinical portion of the program the student will need to be fingerprinted and have a criminal background check completed along with the following.

TEST. The school requires students who are unable to provide a copy of their high school diploma/transcripts to complete a Reading/English assessment test. The assessment is used to assess any areas of additional support; it will not prevent your acceptance into the program. ORIENTATION. All students are required to attend an in-person orientation before starting the program. REQUIREMENTS. It is important to pass and complete all requirements before school starts. Failure to do so may delay the student from starting the program. MEDICAL CLEARANCE. The school required all students to have medical clearance for their doctor. BACKGROUND CHECK. Students who have been convicted of a criminal offense may not be eligible for certificaton (contact the office if this applies).
Student Signature

Clear
Parent/Guardian Signature (if under 18 years of age)

Clear
Date Signed

MonthDayYear
Date
This is to confirm the arrangement under which we will accept payment of your outstanding balance of $1,425 to be paid in full prior to clinical rotation. By signing and submitting this form along with the $375.00 registration fee (non-refundable) indicates admission of the full amount of the account and acceptance of the terms of our agreement.

If there is a default in making any payment, at our option, the full balance owing on the account, together with accrued agreed interest, shall immediately become due and payable and continue to accrue interest, before and after judgment, at the rate of 9% interest until paid off in full.
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CNA Training Registration

Parent/Guardian's Information

Health History

Reminders