Nursing Assistant Training Program
Nursing Assistant Admissions Application:

Give careful consideration to each question on this form. This form must be completed in its entirety for consideration for enrollment.
Email address *
STUDENT ID: *
Your answer
SOCIAL SECURITY NUMBER: *
Your answer
Name (LAST FIRST MIDDLE MAIDEN OR FORMER) *
Your answer
Permanent Address (NUMBER & STREET CITY STATE ZIP) *
Your answer
EVENING PHONE
Your answer
DAYTIME PHONE
Your answer
BIRTHDATE *
MM
/
DD
/
YYYY
AGE *
Your answer
SEX *
DO YOU HAVE A BASIC LIFE SUPPORT CPR CARD? If yes, when is the Expiration date?
IF NOT, DO YOU WANT TO BE ENROLLED IN A CPR/BLS CLASS? (CPR/BLS Class is offered free of charge to YAYA students)
DO YOU HAVE A HIGH SCHOOL DIPLOMA OR GED? If yes, What Year?
HAVE YOU TAKEN ANY COLLEGE MATH AND ENGLISH ASSESSMENT TEST? If Yes, What year?
EXAMINATIONS/VACCINATIONS: TB Screening is required before the start of the program. Immunization paperwork must be submitted to our office a week before the start of the program TB SCREENING…..Required *
REQUIRED ITEMS: *
Required
ETHNIC BACKGROUND: *
Required
Students successfully completing the Nursing Assistant course will be eligible for certification through the State of California. To participate in the clinical portion of the program the applicant will need to be fingerprinted and have a criminal background check completed. This is also required for certification. Applicants who have been convicted of a criminal offense may not be eligible for certification. Please contact our office at (310) 404-6827 or view the certification requirements online at http://www.dhs.ca.gov/Inc/cert/Training.htm


By signing this form you are verifying that you understand the prerequisites and the licensing requirements for the Nursing Assistant program. I understand that falsification or intent to withhold information under penalty of perjury shall constitute grounds for dismissal.

Prior to signing this Enrollment Agreement, you must be given a school catalog containing information regarding the School Performance Fact Sheet, which you are encouraged to review prior to signing this Agreement. These documents contain important policies and performance data for this institution. This institution is required to have you sign and
date the information included in the School Performance Fact Sheet relating to completion rates, placement rates, license examination passage rates, salaries or wages, and the most recent three-year cohort default rate, if applicable, prior to signing this agreement.

I certify that I have received the catalog, School Performance Fact Sheet, and information regarding completion rates, placement rates, license examination passage rates, salary or wage information, and the most recent three year cohort default rate, if applicable, included in the School Performance Fact Sheet, and have signed, initialed, and dated the information provided in the School Performance Fact Sheet.



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