CNA WCE Registration Form

CNA Registration

The cost of this course is $794 (This includes a $15 non-refundable registration fee.)
CNA-CERTIFIED NURSE AIDE PROGRAM

Lecture (64 hours) + Clinical (48 hours) = 112 hours

Textbooks and the state test fee of $125 is included with the tuition. Students are responsible for purchasing a set of ceil blue scrubs for clinical training. Continuing Education tuition and fees are in accordance with the current Panola College catalog. Additional fees may apply.

Registration Requirements:
- Student must be at least 17 years old
- Driver’s license or State issued ID
- Social Security card
- Criminal Background check and Drug Screening
- Proof of immunizations
Students are required to submit to a criminal background check PRIOR to the first day of class. A background search through the Texas Department of Public Safety, Texas Nurse Aide Registry, and Texas HHS Employability Misconduct Registry will also be performed. Any student whose background check is not clear will NOT be allowed to attend classes.

Students must provide proof of the following immunizations by the 3rd day of class:
- Tetanus/ Diphtheria (Tdap within 10 years)
- Measles, Mumps, Rubella (MMR)
- Hepatitis B
- Varicella (2 doses or titer showing immunity)
- Bacterial Meningitis (Students under age 22)
- Negative TB skin test/chest x-ray (within the last year)
Students unable to provide proof of immunization records will not be allowed to attend clinical training and will receive a grade of “NO CREDIT” for the class. Panola College does not provide copies of these records after class completion. ANY pregnant student (no matter what stage of pregnancy) is required to submit proof that she is medically cleared to participate in clinical training with NO restrictions. If the student is unable to provide medical clearance, the student will not be allowed to complete the program. NOTE: Students may contact the Department of State Health Services Immunization Branch hotline at (800)-252-9152 for assistance with immunization record questions.
You will need to submit a photo or copy of your Drivers License or State ID, High School Diploma / GED Certificate, and your Social Security card.
Please upload a photo of information requested.

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Please upload a copy of Immunization

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NURSE AIDE BACKGROUND CHECK

I give Panola College permission to perform a background search from the following websites in accordance with the requirements set forth by the Texas Health & Human Services, (HHS) Chapter 94, Nurse Aides, and the Health and Safety Code, Chapter 250, prior to registering for the Nurse Aide program:

HHS Employability Status Check (includes HHS Nurse Aide Registry and Employee Misconduct Registry)

Texas Department of Public Safety - Criminal History background

If I am married or have been married and divorced, I also give Panola College permission to perform a Criminal Background check on my maiden name as well as my married name(s).

I understand that I must also disclose to Panola College if I have been a Certified Nurse Aide previously or under any name other that the name I am enrolling in at the present time.

My admission into the Nurse Aide program is ultimately determined by the findings of the above searches and those findings will be final.

Have you ever been a Certified Nurse Aide?
Yes     No*

If yes under what name?
Name

Signature*

CONSENT FOR BACKGROUND CHECK AND DRUG SCREENING

I,   First Name*   Last Name*   , recognize that the use and abuse of alcohol, drugs or substances can create an unsafe clinical working environment for others and myself. When requested, I agree to provide a blood, urine, and/or breath sample to a drug-testing laboratory designated by Panola College. I also permit the testing laboratory to release the results of the drug-screening test to designated Panola College authorities.

Initial *   I give permission to Panola College authorities to verify my prescription medications with the prescribing health care provider.

Initial*   In compliance with the clinical affiliates that require a student background check, I give Panola College permission to perform a background check.
Successful completion of a background check does not ensure eligibility for licensure or future employment.

Initial *   I give Panola College Nurse Aide program permission to give copies of the results of my drug screening and/or criminal background check to the Clinical Supervisor, Director of Nursing, or Clinical Human Resource Department at the site I am attending when requested.

Signature*
Payment Information

Call (903) 693-2067 to pay to complete registration.
Refund Policy

If Panola College cancels a continuing education class, a full tuition refund will be made. A 100% refund will be issued if you drop a class through the approved means of notification during our normal business hours two-(2)business days prior to the first scheduled class day. (Example: If the class is on Monday, notification must be given on the Thursday prior to the start of the Monday class.) No refund will be given after that time. Means of notification include: in writing by e-mail (ce@panola.edu), by fax (903-693-1196), or in person at Panola College. (There may be some courses for which refunds cannot be made.) Refunds will take several weeks to process and will be mailed to the student’s listed permanent address.
I acknowledge that I have read and understood the Refund Policy.

I acknowledge.
Should be Empty:

Certified Nurse Aide Registration Form

Ethnicity and Race

Special Population Information

CNA Registration

NURSE AIDE BACKGROUND CHECK

CONSENT FOR BACKGROUND CHECK AND DRUG SCREENING

Payment Information

Refund Policy