Nursing Admissions Application- Nursing assistant

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

Tuition includes the background study clearance fee, finger printing, textbook/workbook and lab fees. 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 county programs. Please send us an email to nursing@primetimemedtraining.com to request tuition assistance options.
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 *
Scrub Top Uniform Order
This section is optional if you plan to order the school uniform from us. Our program uniform is red scrub top with black scrub bottoms. Add $50 to tuition cost. This will be invoiced separately.
Scrub Bottom Uniform Order
This section is optional if you plan to order the school uniform from us. Our program uniform is red scrub top with black scrub bottoms. Add $50 to tuition cost. This will be invoiced separately.
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 tuition is $775 plus $200 for the NATO state exam fee totaling $975. The Application fee as part of the tuition is $50. Applicants must pay the $200 deposit and the $50 application fee to reserve their seat in the nursing assistant cohort within 7 business days of being notified of application approval. If student is having a 3rd party agency cover their tuition cost, the submittal of a payment authorization from said 3rd party payee must be emailed to nursing@primetimemedtraining.com or uploaded to this application using the upload section. If the student fails to submit the $250 within said time frame, they will forfeit their seat into the program and their start date may be postponed. $150 out of the $200 deposit is non-refundable once application is approved and student has accepted their seat. Costs for student program uniform, Basic Life Support CPR training is an optional add on. If a student indicates on their application that they do not have a current Basic Life Support certification, the school will automatically add this training to the student’s tuition at a promotional rate of $50. If the student indicates that they would like to purchase program uniform through our school, an additional $50 will also be added to their tuition cost, otherwise the student will be responsible for the purchase of their program uniform. Uniform colors are red scrub top with black scrub bottoms. Please keep in mind that once a uniform has been issued to student, it is non-refundable. Once a certification has been issued the training for that course is non-refundable. Once a student starts the program, they forfeit their eligibility for a refund. Applicants going through a third party pay source shall notify school as other payment arrangements can be made but must be submitted and approved in writing.
Payment terms on how I want to pay my tuition
These terms are not final, if choosing a payment plan, you will receive a payment invoice and be contacted to enroll in auto payment drafting to pay your invoice as scheduled per your payment arrangement. All payment arrangements must be paid in full before any clinical hours.
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