CERTIFIED NURSE ASSISTANT - FALL 2017
APPLICATION IS CLOSED - NEXT CNA SESSION WILL START IN JANUARY (DATES TO BE DETERMINED)
Choose the CNA schedule you are interested *
Last Name *
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First Name *
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E-mail *
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Phone Number (s) *
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Address *
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City *
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Zip Code *
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Date of Birth *
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Student ID#
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TABE Reading Assessment Score *
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Date of completed Healthcare Essentials *
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What school did you completed Healthcare Essentials *
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Have you ever been convicted of a crime? If your answer is YES, please be advised that the Department of Public Health (CDPH) will not allow CNA certification with convictions. For more information contact the CDPH, Aide Certification Section. 1615 Capitol Avenue, MS 3301, P.O. Box 997416, Sacramento, CA 95899-7416. Phone: 619-2445, or email: cna@dsph.ca.gov *
Do you have any health problems that require medication and / or limit your physical activity? If YES, please explain.
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Are you being sponsored by an agency? *
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