Diversity Nursing Academy Application

3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.

Nursing Assitant School
Students must meet all admission requirements. Complete the admission application form and

submit same to Diversity Nursing Academy electronically or in person. A member of the faculty

will then contact the student for further instructions, regarding background checks and other

medical tests deemed necessary for entry. Credits from previous Nurse Aide courses are not

Diversity Nursing Academy Nurse Aide Program Application
Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Sex:
Address
Mailing Address if different from above
3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.

Nursing Assitant School
Email address
example@example.com
Phone Number
Format: (000) 000-0000.
Please answer the following questions.
1) Do you have a high school diploma?
Other
2) Are you eligible for employment in the United States of America?
Proof of employment Eligibility
Please submit proof.
File Upload

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3) Are you vaccinated? (Proof may be required, as vaccination may be necessary for clinical rotations).
3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.

Nursing Assitant School
4) Have you ever been convicted of a felony or crime?
5) Do you currently work in the health system?
If yes state employer
Please provide the following information.
CNA Status
License Number
Date of expiration

MonthDayYear
Date
Has your license ever been revoked, or have you been denied a CNA license?
6) Do you consent to having the following checks performed?
Background Check
Drug Screen
Covid 19 test
TB Screen
Hep B vaccine
7) Are you vaccinated against covid-19?
Type of vaccine:
Dates

MonthDayYear
Date
Doses
3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.

Nursing Assitant School
8) If not, are you willing to update vaccination status for clinical rotations?
Please provide a copy of your vaccination card.
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Please note that clinical facilities require vaccination for entry. If you are not vaccinated, you may not complete clinical rotations and no other accommodations may be made (Failure to comply with the above screens will be grounds for not being admitted to the program).

Application Fee: $100.00

Please supply two forms of identification.
File Upload

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I understand that all the information submitted in the application is true and I am the responsible party. My signature below also indicates that I have received and agreed to the enrollment agreement. I understand that any falsification of information is grounds for dismal. I agree that if I am accepted into the program an application fee is required. I also agree to comply with all school and state requirements. Please sign below to indicate your consent for all procedures as listed on the application. Students agree that by signing this document the school does not transfer or use credit from another institution.
3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.

Nursing Assitant School
Signature of applicant
Applicant name
Signature and name of parent (if below 18 yrs
Parent (s) Name
Parent (s) Signature
Should be Empty:

3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.

3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.

3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.

3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.

3297 Argent Boulevard, Suite 103 Ridgeland, SC, 29936.