CNA Student Application - $25CNA Application - $25 Fee (Non-Refundable) 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 No Not ApplicableGender 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) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican 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 RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi 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 SaharaYemenZambiaZimbabwePrimary EmailDriver's License Number (no dashes)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)How did you hear about Faith Healthcare Training CenterWhich 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.Did you graduate from high school? Yes NoHigh School Name / Graduation Date / City and StateDid you obtain a GED or equivalent education? Yes NoProgram Name / Completion Date / City and StateDid you graduate from college? Yes NoCollege Name / Graduation Date / City and StateDo 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?Do you have any experience in the healthcare field?Emergency Contact Information:First NameLast NameRelationshipSubmit Registration