Nursing Admissions Application- Nursing assistant/Home Health Aide Program

Nursing Admissions Application
Name *

First Name Middle Initial Last Name
Birth Date *

Month Day Year
Gender *

Male Female Decline to Answer
Are you Hispanic or Latino? *

No Yes Decline to Answer
Race: *

American Indian/Alaskan Native Asian Black Native Hawaiian/Other Pacific Islander White Decline to Answer
Highest level of education completed *
Emergency Contacts (please list at least 2 contacts that can be reachable in case of an emergency include name, relation to you and phone number) *
Do you have a current AHA Basic Life Support CPR card? We offer this class as well.
Certification must be through American Heart Association (AHA)
Is English your first language? Are you willing to complete our basic English test?
Students must be proficient in the English language in order to be successful in the program.
Of which country are you a citizen? *
Are you able to legally work in the U.S. *
Phone *

Area Code Phone Number
E-mail Address *
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Application Fee

There is a non-refundable application fee of $50 and a $200 deposit due at time of application approval to reserve the student's seat in the chosen session or cohort. $100 of the $200 deposit is non-refundable if the student wishes to withdrawal from the program after accepting seat. Tuition includes the background study clearance fee, finger printing, textbook & supplies. If a third party entity is paying the tuition on behalf of the student, please check the "other" box and provide 3rd party payee name and contact number. Please keep in mind that our program is WIOA certified to receive funding from if you are going through CareerForce previously known as Workforce for tuition assistance.
Payment Method: *

Credit Card Mail a Check In-person at school
Are you at least 16 years of age? You must be at least 16 years old to enroll *
Which Cohort are you applying for? *
Tell us why you want to pursue a career as a nursing assistant/home health aide *
How did you find out about us? *
If referred by someone, please provide full name of referring individual
Application Fee/Tuition Payment terms *

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USD The Nursing Assistant/Home Health Aide Application Fee is $50. The Application fee is non-refundable. Tuition is $899 USD. Promotions may be available and are subject to end at school discretion. Applicants must register and have paid the $200 deposit fee within 7 business days of being notified of application approval. If the student fails to submit the $200 deposit within said time frame, they will forfeit their seat into the program cohort. $100 of the $200 deposit is non-refundable once application is approved and student has accepted their seat. Applicants going through a third party pay source shall notify school as other arrangements can be made but must be submitted and approved in writing. A minimum of a $50 non-refundable application fee must be submitted at time of application. The non refundable application fee & deposit are all part of the tuition price.
Payment terms on how I want to pay my tuition
These terms are not final, if choosing a payment plan, a payment contract will be submitted separately with application
By signing below, you are acknowledging that you agree to have read the information in this application in its entirety. You also acknowledge that you are the student enrolling or delegated designee to complete this application. By signing this application form, you are agreeing and acknowledging understanding of the terms and agreements set forth in this document and take full responsibility for the payment of the tuition and fees for the program you are applying to.
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Nursing Admissions Application

Application Fee