Short-Term Training: CNA Pre-Registration

Short-Term Training

CNA Pre-Registration
Name*

First NameMiddle NameLast Name
Former Last Name(s)
Please list any former last names.
Employer
Share where you work if you're registering for this training at your employer's request.
Have you attended Mid before?*

YesNo
If yes, what was your name when you previously enrolled?
Please only enter a response if your name is different now.
Date of Birth*

MonthDayYear
Sex Assigned at Birth*

MaleFemale
Gender Identity*

MaleFemaleNon-Binary/Third GenderPrefer to Self-DescribeOther
Race*

African American or BlackAmerican Indian or Alaska NativeHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite or CaucasianTwo or More RacesOther
Last Four Digits of Social Security Number*
Enter the last four digits of your social security number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*

Area CodePhone Number
Email*
How did you hear about us?*

Social MediaWebsiteEmailBrochure/FlyerRecommended By OthersOther
Select the location where you would prefer to train.*

Harrison CampusMt. Pleasant Campus
Click Here for the upcoming CNA Short-Term Training schedule.
Training Start Date - First Choice*
Training Start Date - Second Choice
How will you pay?*

CashCheckCredit/Debit CardOther
By registering for this training, you are granting Mid Michigan College permission to share your personal information with State and Federal reporting and funding agencies.
Signature*
Today's Date*

MonthDayYear
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