ZTI Nursing Assistant Application

ZTI Nursing Assistant Application

Please have your documents ready to be uploaded on this form or you can send it to admissions@zelinahealthsolutions.com
Applicant Information
Program Applying For
Preferred Start Date (A new cohort starts every 1st and 3rd week of the month)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Alternative Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Legal Last Name
First Name
Middle Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Information
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Apartment
City
State
ZIP
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
Emergency Contact
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Alternative Phone
Please enter a valid phone number.Format: (000) 000-0000.
Admission Eligibility and Program Acknowledgements
I am at least 18 years of age
I possess a valid government-issued photo identification
I can read, write, speak, and understand English sufficiently to safely participate in classroom, laboratory, and clinical instruction
I have regular access to a computer or laptop
I have reliable internet access
I have a working email account
I understand this is a hybrid program requiring online coursework and in-person laboratory and clinical attendance
I understand that admission into the program does not guarantee eligibility for clinical placement
Education Background
Highest Level of Education Completed
If Other, Specify Highest Education Level
School Name
Graduation Year
Health and Clinical Requirements
TB Screening Status
TB Screening Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current BLS/CPR Certification
BLS/CPR Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Proof of Influenza Vaccine or Signed Declination Form
Proof of COVID-19 Vaccine or Signed Declination Form
Physical Examination
Scrub Top size
Background and Conduct
Have you ever been convicted of a misdemeanor or felony that may affect clinical placement?
If yes, please explain
Have you ever been listed on any abuse registry?
Employment History/ Work Experience
Current Employer
Current Position
Healthcare Experience

Other
If Other, specify healthcare experience
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
I have access to (check all that apply)
Do you require reasonable accommodations under the ADA?
If yes, briefly describe the accommodation requested
Demographics and Referral Source
Race/Ethnicity
Gender
Primary Language
How did you hear about Zelina Training Institute?

Other
If Other, please specify how you heard about us
Please upload the required documents, if available. You can also email them to admissions@zelinahealthsolutions.com after application submission for fast processing.

Upload a Govt issued ID card(front and back), immunization record, TB test result (must be not later than 1 year old)
Cancelof
Applicant Certifications and Initials
Please read and acknowledge the following statements
Applicant Signature
Applicant Printed Name
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For Office Use Only
Application Received Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Received By
Application Status
Assigned Cohort
Background Check Status
Drug Screen Status
TB Documentation Status
Enrollment Agreement Status
Payment Status
Comments
Admissions Representative Signature
Admissions Representative Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Should be Empty:

ZTI Nursing Assistant Application

Applicant Information

Contact Information

Emergency Contact

Admission Eligibility and Program Acknowledgements

Education Background

Health and Clinical Requirements

Background and Conduct

Employment History/ Work Experience

Demographics and Referral Source

Applicant Certifications and Initials

For Office Use Only