CNA Application

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

QUESTION #2- Do you have proof of receiving the Covid Vaccinations? Please bring it with you during orientation!

Yes

QUESTION #3 - Do you have a document for a medical or religious exemption? Please bring it with you during orientation!

Yes

First Name

Middle Name

Last Name

Birthday (MM/DD/YYYY)

Are you a citizen of the United States?

Yes

Are you at least 18 years of age?

Yes

Is English your primary language?

Yes

If English is NOT your primary language, have you taken any ESL (English as a Second Language) classes?

Yes

Gender

Male

Female

Prefer not to answer

Address

Address Line 1

City

State

Zip Code

Country

Primary Email

Driver's License Number (no dashes)

Social Security Number (Required for background check) *If you do not have a SSN, enter all 1's

Race (Required for Background Check)

State of Birth (Required for Background Check)

Country of Birth (Required for Background Check)

How did you hear about Faith Healthcare Training Center

Which Social Media platform do you use most often? Facebook, Instagram, or Twitter

Have you ever been convicted of a felony?

Yes

If 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

If yes, specify those restrictions or accommodations.

Did you graduate from high school?

Yes

High School Name / Graduation Date / City and State

Did you obtain a GED or equivalent education?

Yes

Program Name / Completion Date / City and State

Did you graduate from college?

Yes

College Name / Graduation Date / City and State

Do you have a learning disability, IEP or 504 Plan? (This will allow us to assist you during the course)

Yes

Please explain

Why are you pursuing to become a Certified Nursing Assistant?

Do you have any experience in the healthcare field?

Emergency Contact Information:

First Name

Last Name

Relationship