TSNA CNA Program Application Screening Form

TSNA CNA Program Application Screening Form
Thank you for your interest in The Stephanie Nursing Academy!

We are proud to offer a comprehensive CNA training program rooted in compassion and excellence. This screening form helps us learn more about you before scheduling an interview. Please complete all fields honestly. You must be at least 16 years old to apply.
Basic Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you currently employed or in school?*
Instagram and/or Facebook name(s)*
CNA Program Fit
Why do you want to become a CNA?*
Are you a minor (under 18 years old)?*

YesNo
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Note: “Minors must be at least 16 years old to enroll.”
Do you have any criminal background?*

YesNo
Can you commit to at least 12–14 weeks of weekend CNA training?*

YesNo
Note: “Length may vary depending on holidays.”
Are you able to attend mandatory clinicals that may be outside of the Antelope Valley?*

YesNo
Do you have reliable transportation to attend class and clinicals?*

YesNo
Do you have a strong support system to help you succeed during this program?*

YesNo
Tell us a little about your support system. Who are they, and how do they support you?*
What challenges do you anticipate, and how do you plan to address them?*
Referral Info
How did you hear about us?

InstagramFacebookTikTokGoogleReferralOther
Who referred you?*
Final Reflection
What does being compassionate mean to you?*
Program Interest
Which program are you interested in?*

Weekend ProgramDay Program
Commitment Confirmation
Are you willing to commit to the 12–14 week weekend program?*

YesNo
Are you willing to commit to the 6–8 week weekday program?*

YesNo
Social Media
Do you have a Facebook account?*

YesNo
What is your Facebook name or handle?*
Do you have an Instagram account?*

YesNo
What is your Instagram name or handle?*
Do you have a TikTok account?*

YesNo
What is your TikTok name or handle?*
DISCLAIMER:
This pre-application form does NOT guarantee you a spot in the class. After submission, a faculty member will review your information. If selected, you will be contacted within 24–48 hours to schedule an interview as the next step.
Should be Empty:

TSNA CNA Program Application Screening Form

Basic Information

CNA Program Fit

Referral Info

Final Reflection

Program Interest

Commitment Confirmation

Social Media

DISCLAIMER: