CNA PROGRAM APPLICATION DAY & NIGHT OPTIONS

CNA PROGRAM APPLICATION DAY & NIC OPTIONS
STUDENT INFORMATION
Full Name:*

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth (MM/DD/YYYY):*

MonthDayYear
Date
Are you 18 or older?*

YesNo
Email:*
example@example.com
Phone Number:*
CRIMINAL HISTORY
Have you ever been convicted of a felony or any criminal charge?*

YesNo
If YES, list the charge(s), date(s), and details:
CLINICAL AVAILABILITY
Preferred Clinical Day (Choose One):*

FridaySaturdaySunday
REQUIRED DOCUMENTS
Do You have a Valid ID?*

YesNo
Do you have a High School Diploma / GED?

YesNo
Do you have a Physical? (We offer this first day of class )( Must have been completed in the past 12 months )*

YesNo
Do you have a Background Check ?( Must have been completed in the past 12 months )

YesNo
Do you have a Up-to-Date TB Skin Test ?( Must have been completed in the past 12 months )*

YesNo
Do you have a Up-to-Date BLS ?(Must be from American Red Cross , American Heart Association )(We offer BLS class )*

YesNo
Do you have a Drug Screen done in the past 12 months ? ( We offer these first day of class)

YesNo
Do you have a Up-to-Date Hep B Or Declination ?(This would be on your shot record you can get from MYIRMOBILE.COM or the Health Department )*

YesNo
Do you have a Covid Vaccine Or Exemption Form?(This would be on your shot record you can get from MYIRMOBILE.COM or the Health Department )*

YesNo
You understand all of these documents have to be turned in By the 3rd day of class or it can risk delayed clinical schedule .All documents can be emailed to ATMSTUDENTDOCS22@GMAIL.COM*

YesNo
PROGRAM SCHEDULE ACKNOWLEDGEMENT
Day Schedule: Monday Friday, 9 AM 4 PM (2 weeks)

(Clinical sessions will be scheduled within this timeframe; however, dates and times may be adjusted as needed to best accommodate the classroom and learning environment.)
Night Schedule: Monday Friday, 5:30 PM 9 PM (3 weeks)

(Clinical sessions will be scheduled within this timeframe; however, dates and times may be adjusted as needed to best accommodate the classroom and learning environment.)
I understand and agree to the schedule.*

YesNo
Select which class date you are signing up for.*

Day Feb 2nd 2026 -Feb 13thNight Feb 2nd 2026 - Feb 20thDay March 2nd 2026 - March 13thNight March 2nd 2026 - March 20th

My Products*

Cna Deposit Deposit is non refundable and can only be transferred one time after deposit and information is received we will contact you with all information needed .

$100.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Afterpay

SIGNATURE
Student Signature:*

Clear
Print Name:*
Date:*

MonthDayYear
Date
Should be Empty:

CNA PROGRAM APPLICATION DAY & NIC OPTIONS

STUDENT INFORMATION

CRIMINAL HISTORY

CLINICAL AVAILABILITY

REQUIRED DOCUMENTS

PROGRAM SCHEDULE ACKNOWLEDGEMENT

Payment Methods

SIGNATURE