CNA Program Information Form

CNA Program Application Form
General Information
Thank you for your interest in the Certified Nursing Assistant Training Program located at The Education Corps-Pico Union, a charter school managed by Los Angeles Education Corps. Our goal at the TEC Pico Union CNA program is to offer a comprehensive entry-level program into the field of nursing.

There are some pre-requirements that must be completed before you can be considered as a candidate for entry into the program. Please review the steps we have listed below and be sure to fill out the application documents that are linked below.

We encourage you to start the process for acceptance three to four weeks in advance. These initial requirements are part of the California Health and Safety code HSC, 1338.5(2)(A) which states that all students who wish to enroll in a Nursing Assistant Training Program (NATP) must (1) successfully pass a fingerprinting background check, (2) provide proof of a clear tuberculosis/PPD test, and (3) provide proof of a recent physical exam, including a medical history and COVID 19 proof of vaccination (as per Title 22 CCR 71835 F).

Our staff will be happy to help guide you through this process. Also, if you are a current student in our high school diploma program, who is in good standing (for example, good attendance, passing classes, etc.), then you may be eligible for financial assistance from our school to help pay for this process (please see the principal or program director).

THE DEADLINE FOR RECEIPT OF APPLICATIONS FOR THIS COHORT IS JUNE 21, 2024. Uploading documents to this portal is acceptable to meet the deadline but you will need to bring the originals to the office when you come in person at a later date.
Instructions for Completing Required Steps
Here are details on the steps you will need to complete before enrolling in our CNA program:

Step One: Complete a fingerprint and background check with the Department of Justice and be cleared prior to starting the CNA program. Two locations have been provided for you; one is close to the school campus, but you can choose your own location if you like. We will give you a form to have the results sent. Keep your receipt. Some fingerprinting location options include:

7 Days Live Scan and Fingerprint

2687 1⁄2 W. Pico Blvd.

Los Angeles, CA 90006

(213) 365 1060

www.7dayslivescan.com

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AMF Income Tax Services and Live Scan

3227 W.Century Blvd.

Inglewood, CA 90303

(310) 677-5000

www.amf-tax.com

Step Two: Have a medical history and physical examination that includes a tuberculosis/PPD test, and provide clearance of your TB test and your physical exam in writing by your doctor. Some local options for physical and TB tests are:

1) Dr. Nguyen ofc. (213) 480-1338

2) T.H.E Clinic, 3834 S. Western Ave. (323) 730-1920

Step Three: Complete the Certified Nursing Assistant Initial Application Form and be sure to turn in all original documents in Steps 1-3 to the main office at the Pico Union campus located at 1403 S. Union LA, CA 90015. You can also upload them below to meet the June 21st deadline, but we will still need the original documents when you come to TEC Pico Union in person.

Step Four: After you complete Steps 1-3, the school's front office will give you an Agreement Of Understanding (AOU). We are not guaranteeing you entry into our CNA training program, as spaces may be limited. Additionally, our CNA program is a "training program” and not a paid job or an offer of employment (just to be clear). The AOU confirms that you understand that and that you have completed all of the pre-requirements. Sign and turn in the AOU, and you will have completed all of the pre-requirements necessary to be considered as a candidate for entry into the program.

Get started below!
Questionnaire

Complete all the questions below to begin the process of becoming a candidate to enroll in TEC Pico Union CNA.
Your Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender Identity

FemaleMaleTransgenderNon-binary/non-conformingPrefer not to say
Date of Birth

MonthDayYear
Date
Race and/or Origin

Black and/or African AmericanHispanic, Latino, or Spanish OriginAmerican Indian or Native AmericanAsian or South AsianNative Hawaiian or Pacific IslanderWhiteOther Race or Origin
Marital Status
Are you a parent or primary caregiver?
Are you currently homeless or have you been homeless in the past year?
Have you ever been in foster care?
Are you economically disadvantaged?

YesNo
Are you an English Language Learner?

YesNo
Do you identify as LGBTQ?

YesNo
If you attend college after high school, will you be considered a first-generation enrollee?

YesNo
Do you have disability?

YesNo
Are you registered to vote?

YesNoNot eligible to vote
Are you considered a youth or adult offender?
If yes, what is the most recent release date?

MonthDayYear
Date
What is your current court involvement?
What is the level of the most serious offense?
Phone Number
Please enter a valid phone number.
Email
example@example.com
Are you a citizen of the United States?

YesNo
Education
Name of High School
Location
Highest Grade Completed
Starting Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
If you did not complete high school, what challenge(s) got in the way?

Needed to get a jobEnglish is a second languagePregnancy/ParentingIncarcerationGang InvolvementHomelessnessUnsafe school environmentBad gradesBullyingSubstance AbuseExpelledOther Challenge(s)
Anything else you would like to share about what stood in the way of your diploma?
What is your post-secondary goal?

Associate's degreeBachelor's degreeGraduate/Professional degreeCertificateApprenticeship PlacementEmployment OnlyUndeclared
Language Ability

EnglishSpanishTagalogFrenchChinesePersian (Farsi)ArmenianJapaneseKoreanRussianOther
How did you hear about us?
Feel free indicate more than one source of information.

Friend/family memberSaw the banner on the buildingSocial mediaProbation/Parole OfficerSocial WorkerSchool Counselor/TeacherFlyerWebsiteOther
Required Documents
Upload your completed files to this portal.

Cancelof
Thank you for completing the above Questionnaire.

The next step towards enrolling into TEC Pico Union CNA program is to complete the following forms:
- Certified Nurse Assistant Initial Application
- Request for Live Scan Service
- Physical Clearance
- Tuberculosis Test
You can download all of the above forms here and print them out. If you don't have a printer, you can stop by and pick the forms up at TEC Pico Union, 1403 S. Union Ave., Los Angeles, CA 90015. Call first to ensure that the office is open: (213) 389-3103.

Once you have completed all forms you can:

1) Scan them and then upload them into the portal below, or

2) Drop them off at TEC Pico Union.
Checklist
Here's a handy checklist of all the documents you will need to complete or gather in order to complete the pre-enrollment process. If you need support in getting things done, contact Ms. Aysia at amiddleton@laedcorps.org.

Agreement of Understanding (This will be handed to you by the TEC Pico Union staff after you complete all of the other steps to enrolling)Parent Signature and ID (if applicable) on the Agreement of UnderstandingQuestionnaire (above)Certified Nursing Assistant Program Initial Application (document in above link)Live Scan Background Check (document in above link)Physical Exam (document in above link)TB Test (part of the physical exam)COVID Vaccination (present proof of vaccination - card or other document -at TEC Pico Union when picking up AOU)State ID (present at TEC Pico Union when picking up AOU)Social Security Card (present at TEC Pico Union when picking up AOU)
Submission
THE DEADLINE FOR RECEIPT OF APPLICATIONS FOR THIS COHORT IS JUNE 21, 2024. Uploading documents to this portal is acceptable to meet the deadine but you will need to bring the originals to the office when you come in person at a later date.
Let us know how you plan to proceed:

I am submitting my questionnaire right now, as well as uploading all the necessary forms so that the pre-enrollment process can begin. I will come to the TEC Pico Union CNA program office to show my IDs and all my original documentation (including my initial CNA app, TB test and physical form) and pick up/sign the AOU form.I am only submitting my questionnaire at this point. I have downloaded here and will later submit my forms at the TEC Pico Union CNA program office. At that time I will show my IDs and all my original documentation (including my initial CNA app, TB test and physical form) and pick up/sign the AOU form.I am only submitting my questionnaire at this point. I plan to pick up and later submit my all my original documentation (including my initial CNA app, TB test and physical form) at the TEC Pico Union CNA program office. At that time I will show my IDs and other documentation and pick up/sign the AOU form.
Should be Empty:

CNA Program Application Form

General Information

Instructions for Completing Required Steps

Questionnaire

Education

How did you hear about us?

Required Documents

Checklist

Submission