Charisma SPD – CNA Training Application

1
Are you applying for New CNA Training or Returning/Re-enrolling?* This field is required.
New CNA Training
Returning/Re-enrolling
2
Preferred class format* This field is required.
In-Person
Hybrid
Online theory + in-person clinical (if offered)
3
Preferred schedule* This field is required.
Weekdays (Day)
Weekdays (Evening)
Weekends
Flexible
4
Preferred location* This field is required.
Bronx/NY area
Other (Specify)
5
Preferred location (city/state)* This field is required.
6
Are you 18 years or older?* This field is required.
Yes
No
7
Full Legal Name* This field is required.
First Name
Last Name
8
Preferred Name (if different)
9
Phone Number* This field is required.
Please enter a valid phone number.
10
Email Address* This field is required.
example@example.com
11
Date of Birth* This field is required.
Date
Month
Day
Year
12
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Preferred contact method* This field is required.
Call
Text
Email
14
Emergency Contact Name* This field is required.
15
Emergency Contact Relationship* This field is required.
16
Emergency Contact Phone* This field is required.
Please enter a valid phone number.
17
Are you authorized to work in the U.S.?* This field is required.
Yes
No
18
Will you require sponsorship now or in the future?* This field is required.
Yes
No
19
Highest education level completed* This field is required.
Please Select
Please Select
Less than High School
High School Diploma or GED
Some College
Associate Degree
Bachelor's Degree
Graduate Degree
Other
20
Are you able to read, write, and speak English sufficiently for training and clinical communication?* This field is required.
Yes
No
21
Do you have reliable transportation to attend classes/clinical?* This field is required.
Yes
No
22
Can you meet the physical requirements of the program (standing, lifting, assisting patients)?* This field is required.
Yes
No
23
Explain any accommodations needed for physical requirements.* This field is required.
24
Upload Government-issued Photo ID (PDF, JPG, PNG only)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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25
Upload Proof of Address (PDF, JPG, PNG only, optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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26
Upload Resume (PDF, JPG, PNG only, optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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27
Do you have a Social Security Number?* This field is required.
Yes
No
28
Last 4 digits of SSN* This field is required.
29
Reason/Status (if no SSN)* This field is required.
30
Are you willing to complete required health clearances for clinical (immunizations, TB test, physical) if required by the clinical site?* This field is required.
Yes
No
31
Are you willing to complete background check / drug screening if required by the clinical site?* This field is required.
Yes
No
32
Do you currently hold CPR certification?* This field is required.
Yes
No
33
Upload CPR card (PDF, JPG, PNG only, optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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34
Do you need CPR included?* This field is required.
Yes
No
35
Any prior healthcare experience?* This field is required.
Yes
No
36
Describe your prior healthcare experience (role, facility, dates)* This field is required.
37
Previous enrollment date* This field is required.
Date
Month
Day
Year
38
Reason for returning (explain)* This field is required.
39
Upload prior completion/attendance records (PDF, JPG, PNG only)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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40
Why do you want to become a CNA?* This field is required.
41
Work preference after completion* This field is required.
Nursing home/rehab
Hospital
Home care
Any
42
Do you want job placement assistance after training?* This field is required.
Yes
No
43
How will you pay for your training?* This field is required.
Self-pay
Employer-sponsored
Program/Grant (if applicable)
Other
44
Sponsor/Employer Name* This field is required.
45
Sponsor/Employer Contact Name* This field is required.
46
Sponsor/Employer Contact Email* This field is required.
example@example.com
47
Sponsor/Employer Contact Phone* This field is required.
Please enter a valid phone number.
48
Any billing notes (optional)
49
Do you need an invoice/receipt?* This field is required.
Yes
No
50
Billing email for invoice/receipt* This field is required.
example@example.com
51
Policies and Consents: Attendance, punctuality, code of conduct, clinical participation requirements, refund/reschedule policy. Please review and agree to the following:
52
I certify the information provided is true and complete.* This field is required.
I certify the information provided is true and complete.
53
I understand completion requires attendance and meeting course/clinical requirements.* This field is required.
I understand completion requires attendance and meeting course/clinical requirements.
54
I authorize Charisma SPD to contact me by phone/text/email about enrollment and scheduling.* This field is required.
I authorize Charisma SPD to contact me by phone/text/email about enrollment and scheduling.
55
I acknowledge the refund/reschedule policy.* This field is required.
I acknowledge the refund/reschedule policy.
56
Electronic Signature* This field is required.
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57
Date Signed* This field is required.
Date
Month
Day
Year
58
Anything else you want us to know?
59
Thank you for applying to Charisma SPD CNA Training. We will contact you with scheduling, requirements, and next steps.
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