Community-Based Residential Facility (CBRF) Training Registration Form

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Thank you for choosing Core Care Healthcare Training Center, LLC. for your healthcare training needs. We are excited to have you join our class! Please complete the registration form completely and submit your form.
We will be in contact via email to complete the registration process, and to discuss payment options.

Payment accepted:
1. SQUARE PAYMENT Invoice -CREDIT OR DEBIT CARD (VISA, MASTER CARD, AMERICAN EXPRESS) ONLINE VIA PAYMENT OF EMAILED INVOICE
2. CASH PAYMENT (IN FULL)- TWO BUSINESS DAYS PRIOR TO START OF TRAINING
3. MONEY ORDER OR CASHIER'S CHECK PAYABLE TO CORECARE HEALTHCARE TRAINING CENTER, LLC. C/O TERESA GUYTON
4. ZELLE PAYMENT- PLEASE CONFIRM THIS OPTION FIRST
************NO CHECKS**************

Please Note: Classes are are offered Monday-Friday (A.M.) Weekends classes are offered twice monthly. If you are are interested in group staff training, or have questions regarding class schedules please contact us via phone or email.

Thank you.

Core Care Healthcare Training Center, LLC.
6830 W. Villard Ave.
Milwaukee, WI.
Phone: 414-458-1661
Email: corecarecbrftraining@gmail.com
Website: www.corecarecbrftraining.com

Email *

Today's Date *

YYYY

Student Name (First, Middle Initial, Last) -Please list full name and check spelling for state registry purposes. *

Date of Birth *

YYYY

Address, City, State, Zip *

Phone Number *

Basic Skills Screening Tool (Check All That Apply) *

I am 18+ years

I am currently enrolled in High School (does not include GED or HSED programs)

I have a High School Diploma, GED, Certificate, or HSED

I can follow basic written instruction and diagrams with no help or just a little assistance.

I can add, subtract, multiply, and divide with whole numbers up to 3 digits.

I speak and read English well enough to gain employment and keep employment.

I require special learning accommodations.

I have worked with clients with developmental or physical disabilities before.

I am interested in additional training with Core Care Healthcare Training Ctr. LLC. (CPR, CNA)

I speak a second language, and may need an interpreter.

Other:

Required

Name of Employer (If your training is through your employer, please list Name, Address, Phone Number, and Email Address if available) List N/A if No. *

What date are you interested in starting training? *

YYYY

How would you like to complete your training? Please note: Medication Administration is a two part training. This course can be completed hybrid (virtual and Part 2 in person). If opting for virtual medication training, participants MUST have a valid verifiable testing proctor available for skills demonstration portion before testing virtually. *

Virtual

In-Person

Medication Administration (Hybrid)

CBRF Training (Weekday Mornings/ Weekend Saturday/Sunday start times may vary) Please contact for group rates for staff training. *

C/o 2022 Offer- $250 Limited Spots

CBRF Registry (4) All Components $495+$20 Registry Fee+tax. Medication Administration, Standard Precautions, Fire Safety, First Aid & Choking

C.E.U- Continuing Education Units $300 + tax per person

Medication Administration $200+$20 Registry Fee + tax Part 1&2 (14 Hours)

Standard Precautions $85+$20 Registry Fee + tax (2 Hours)

Fire Safety $125+$20 Registry Fee + tax(5 Hours)

First Aid & Choking $125+$20 Registry Fee + tax (4 Hours)

Client Group/ Challenging Behaviors $100

Dietary Needs & Meal Planning $100

Residents Rights $100

Needs Assessment & ISP Planning $100

Understanding Diabetes $100

Manager's Training -$350

Staff Training Group Rate- TBD (Please Contact)

Other:

Required

Additional Training & Workshops (Weekends Only Saturday/Sunday) Please contact for Weekday Training *

Manager's Training -$350

Career Readiness Workshop Adults- $60 Interview Coaching (Ex. Mock Interview & Tips)

Resume Development & Revision Assistance Services- $60

Career Coaching Session/Workshops for Teens (Ages 14-19 yrs) Specific Days

N/A

Required

Registration for classes require FULL payment to hold a seat for training. CCHTC is a service based business, therefor instructors are compensated for class prep time and materials. SPECIAL NOTE: CLASSES HAVE BEEN ADJUSTED DUE TO THE MOST RECENT COVID-19 PANDEMIC. YOUR SAFETY IS OUR PRIORTY. 1.Students must bring and wear a mask at all times during class. 2.Gloves, sanitizer, and PPE equipment will be available for skills portion of training. 3. Social distancing will be maintained at all times. 4.If you feel ill or present symptoms of COVID-19 (fever, sore throat, coughing, vomiting, body aches, chest pain or SOB) before class DO NOT COME TO CLASS. 5. Students may be asked to leave if signs of illness are present on day of training. 6. Classes of 6 students or less will be held at Core Care Healthcare Training Center's location. If your facility permits space for more than 6 students or staff to be trained while adhering to CDC's social distancing recommendations, no more than 10 students will be trained at once. Please agree with terms below: *

I agree that no seat will be held for training without a completed registration form and full payment before training date.

I agree if I am unable to attend my scheduled training date, I must contact CCHTC at least 3 business days prior to training to reschedule.

I agree payment for classes are non-refundable. Exceptions maybe made only by CCHTC's Instructors.

I agree that at times class schedules and locations may change. Instructors will notify students if this should happen. Payment will be honored at instructor's discretion.

I agree in the result of inclement weather, conflict of parties, or unforeseen emergencies instructors reserve the right to cancel classes at any time.

I confirm that I DO NOT currently have symptoms of COVID-19.

I confirm that I HAVE NOT been in contact with anyone presenting symptoms, been diagnosed, or recently hospitalized for COVID-19.

I confirm that I have not traveled out of the state within the last 30 days.

I agree that I am required to wear a mask to class and maintain social distancing on the day of training.

I agree that if I become ill in anyway, I will contact my instructor immediately before class, and WILL NOT show up to class.

I agree that if I present any signs of illness during class (fever, excessive coughing, flu-like sympyoms, etc.) I may be asked to leave training by my instructor.

Required

eSignature Agreement- By purchasing a service and reviewing the above terms, I agree to all statements and terms. I acknowledge by typing my name electronically, I have read and agreed to the polices and terms listed above and I am bound to the outlined contract with Core Care Healthcare Training Center, LLC. Core Care has the right to amend and or terminate services/ contract agreement at anytime. *

Send me a copy of my responses.

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