CNA Student Application - Free (Indy Met High School)CNA Application - Indy Met High School IMPORTANT - PLEASE READ!!!! In order to complete the CNA Course, you must complete clinicals in a long term care facility (nursing home). The facilities that we are partnered with REQUIRES students to be FULLY VACCINATED prior to attending clinicals unless you have a documented medical or religious exemption. IF YOU HAVE NOT RECEIVED THE VACCINATION, DO NOT HAVE PLANS ON RECEIVING THE VACCINATION OR DO NOT HAVE SUPPORTING DOCUMENTATION FOR AN EXEMPTION, DO NOT COMPLETE THIS APPLICATION! Answer the first (3) questions prior to starting the application..... QUESTION #1 - Have you received the Covid Vaccinations? Yes NoQUESTION #2- Do you have proof of receiving the Covid Vaccinations? Please bring it with you during orientation! Yes NoQUESTION #3 - Do you have a document for a medical or religious exemption? Please bring it with you during orientation! Yes NoFirst NameMiddle NameLast NameBirthday (MM/DD/YYYY)Are you a citizen of the United States? Yes NoAre you at least 18 years of age? Yes NoIs English your primary language? Yes NoIf English is NOT your primary language, have you taken any ESL (English as a Second Language) classes? Yes NoGender Male Female Prefer not to answerAddressAddress Line 1CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePhone NumberPrimary EmailDriver's License Number (no dashes) *If you do not have a Driver's License, enter all 1's*Social Security Number (Required for background check) *If you do not have a SSN, enter all 1'sRace (Required for Background Check) State of Birth (Required for Background Check)Country of Birth (Required for Background Check)Which Social Media platform do you use most often? Facebook, Instagram, or TwitterHave you ever been convicted of a felony? Yes NoIf yes, please include specific information including the date of felony charge, nature of felony, which court and final outcome. Include copies of the court documentation is available.Do you have any physical condition(s) or any other condition(s) which would limit your ability to perform essential job-related functions? Yes NoIf yes, specify those restrictions or accommodations.Do you have a learning disability, IEP or 504 Plan? (This will allow us to assist you during the course) Yes NoPlease explainWhy are you pursuing to become a Certified Nursing Assistant?Emergency Contact Information:First NameLast NamePhone NumberRelationshipSubmit Registration