Nurse Aide 1 Student Application Form

1
Full Name* This field is required.
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Phone Number* This field is required.
4
Email Address* This field is required.
example@example.com
5
Address* This field is required.
6
City* This field is required.
7
State* This field is required.
8
Zipcode* This field is required.
9
SSN* This field is required.
10
Are you currently in High School?* This field is required.
YESNO
11
If YES name of High School
12
If NO please provide your high school college or GED information
13
School Name
14
City State
15
Graduation Year
16
Please select the program you are interested in:* This field is required.
Please Select
Please Select
Nurse Aide I Day (8am-2:30pm)
Nurse Aide I Evening (3pm-9:30pm)
Nurse Aide I Weekend Accelerator (8am-2:30pm Friday-Mondays)
Nurse Aide I Refresher (Scheduled on demand)
17
Payment Plan* This field is required.
Please Select
Please Select
Self-Pay
Vocational Rehabilitation
NC Works
Novant Health Scholarship
18
Are you currently employed?* This field is required.
YESNO
19
Employer Name
20
Current Position
21
Manager's Name
Employer Name
Last Name
22
Manager's Phone Number
23
Manager's Email Address
24
Previous Employment (if applicable)
25
Employer's Name
26
Position Held
27
Dates of Employment
Date
Month
Day
Year
28
Reference #1 Full Name* This field is required.
Full Name
Last Name
29
Relationship* This field is required.
30
Phone Number* This field is required.
31
Email Address* This field is required.
example@example.com
32
Reference #2 Full Name* This field is required.
Full Name
Last Name
33
Relationship* This field is required.
34
Phone Number* This field is required.
35
Email Address* This field is required.
example@example.com
36
Nurse Aide 1 Application Fee
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Nurse Aide I Application FeeA $10 fee is required to process this application.
$10.00Edit
Back
Total cost $0.00
First Name
Last Name
37
Sign Here* This field is required.By signing below, I confirm that all the information provided in this application is accurate andcomplete. I understand that submitting this application does not guarantee admission into theprogram nor does it reserve a space in any class. A spot is only secured once all admissionrequirements are met and a deposit or full tuition payment is made.
Clear
38
Image Field
Should be Empty: