CNA/CMA Training Program Application

Customer Details:

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

How did you hear about us?*

Please Specify*

What classes are you interested in?*

CNACMAACMA or UpdateCPR

Which CNA class start dates are you interested in? Select “other” for CMA. April is currently full. SNAP recipients please select the waitlist option.*

Are you currently CPR Certified? If not, AHA Adult/Infant/Child CPR with AED and First aid is $100. CPR is included in your total tuition cost and will be applied to your balance. *

Are you interested in a payment plan or needing financial assistance?

YesNoMaybe

Do you have your GED or High School Diploma?*

YesNo

Do you consent to a background check? Required for enrollment.*

YesNo

Are you at least 16 years of age?*

YesNo

By checking this box, I consent to receive communication from EmpathyEd, including text message, emails, and phone calls.*

YesI decline