CNA Student Registration Form

CNA Student Registration Form

CNA Student Registration Form

Provide your details, credentials, and signature to secure your registration for the Certified Nursing Assistant programs.
Student Information
Full Name (as shown on your government ID).*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code

Student Information
Are you 18 years of age or older?*

YesNo
Are you able to pass a criminal background check?*

YesNo

Student Information
Are you Applying for CNA Program? CNA Programs: Tuition fee is $950 plus taxes. Non-refundable registration fee of $50 is included in the tuition fee and must be paid upon completing this registration form. The remaining tuition balance is due one week before the class start date, and if paid in 2 instalments a $20 service fee is added to the fees and the other half is due by the 7th day of class.*

YesNo

Background Check Acknowledgment
Criminal Record Disclosure - I understand that I must pass a background check and that a criminal record may limit my clinical placement and future job opportunities.*

Agree

Electronic Signature Requirements

By checking the boxes below, I certify that I have read & I do meet the requirements of the program and that the information provided is accurate and true to my knowledge.
Signature*
Date of Signature - Must be on the same date you are completing this form.*

MonthDayYear
Date
Final Step: select and complete the registration fee below.

My Products*

Registration Fee (Deposit) Product Image

Registration Fee (Deposit)

This is a non-refundable registration fee that secures your seat in this course.

$50.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

Should be Empty: