Training Course Signup
Participant Registration Form
Applicant Information
Name
*
First Name
Last Name
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
State DL/ID #
Social Secuirty #
Birthday
-
Month
-
Day
Year
Date
Select Session
Please Select
Winter Start Date
Spring Start Date
Summer Start Date
Fall Start Date
Have you ever worked in healthcare?
Yes
No
Are you a citizen of the United States?
Yes
No
If no, are you authorized to work in the U.S.?
Yes
No
Have you ever been convicted of a felony?
Yes
No
If yes, when?
Explain Misdemeanors if any:
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Education
High School
City, State
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Did you graduate?
Yes
No
Diploma
College/Other
City, State
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Did you graduate?
Yes
No
Degree
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References
Professional and Personal
Name/Company
Professional Reference
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name/Relationship
Personal Reference
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name/Relationship
Personal Reference
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Most Recent Employment
If Any
Company
Address
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Supervisor
Job Title
Responsibilities
May we contact your previous supervisor for a reference?
Yes
No
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Acknowledgements
Please initial all of the below
Eligibility: I am 18 years or older and will provide proof of identity and authorization to work upon request.
*
Attendance: I have reviewed the 100-hour course schedule and am available to attend all dates. I understand missed dates may affect eligibility for the issuance of a complete certificate.
*
Dress Code: I understand a dress code is required and agree to wear the required uniform during all class sessions and on-site clinicals.
*
Photo Release: I hereby grant Home Health Companion Services and affiliates permission to use my likeness in a photograph, video, or other source of media in any and all of its publications. I understand and agree that any photograph using my likeness will become property of Home Health Companion Services and will not be returned. I acknowledge that since my participation with Home Health Companion Services is voluntary, I will receive no financial compensation, now or in the future. I hereby irrevocably authorize Home Health Companion Services and affiliates to edit, alter, copy, exhibit, publish or distribute this photo for any related & lawful purpose and waive the right to inspect or approve the finished product.
*
Essential Job Functions: I understand the Nurse Aide training program essential functions & acknowledge these requirements are able to be met during on-site clinicals.
*
Confidentiality: I will ensure all program, training and/or resident/medical information is maintained as confidential and will not be shared with anyone outside of the program.
*
Drug Testing Consent: I hereby consent, upon a request, to submit to a drug or alcohol test and I further consent to allow the results of such screen can be made available to the partnering agencies of, Home Health Companion Services for purposes of the clinical facilities and/or future employment.
*
TB Screen: I agree to provide Home Health Companion Services a copy of required current Mantoux/TB Test Results (within 1 yr) or Chest X-Ray (within 2-yr).
*
Grievances: Concerns/Complaints about the school, instructors and/or coursework should follow the grievance process outlined in the course catalog. Grievances may be escalated to the TWC & information can be found at the TWC Career Schools website @http://csc.twc.state.tx.us/
*
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Payment
Tuition = $900 Registration = $ 150.00 Books & Supplies = $150.00 Other Costs = $0.00 Total Program Cost = $1200.00 to be paid in full to Home Health Companion Services as follows: Any holder of this consumer credit contract is subject to all claims and defenses which the debtor could assert against the seller of goods or services obtained pursuant hereto or with the proceeds hereof. Recovery hereunder by the debtor shall not exceed the amounts paid by the debtor hereunder.
My Products
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( X )
Tuition = $900
$
900.00
Registration = $150
$
150.00
Books & Supplies = $150
$
150.00
Submit
Should be Empty: